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QUALITATIVE METHODOLOGY

Quantitative versus qualitative research: Methodological or ideological dichotomy?

Juan Luis González López,^1,2 Paloma Ruiz Hernández^2
1Universitary School of Nursing, Physiotherapy and Podology, Complutense University (UCM), Madrid, Spain. ²University Clinical 'San Carlos' Hospital, Madrid, Spain

Mail delivery: Juan Luis González. C/ Cuevas de Altamira 5, 28054 Madrid, Spain

Manuscript received by 9.19.2010
Manuscript accepted by 12.11.2010

Index de Enfermería [Index Enferm] 2011; 20(3): 189-193

How to cite this document

Abstract 

Critical revision of the historical antagonism between qualitative vs. quantitative research in Health Sciences. We analyze the differences and inferences between both methodologies, concluding that quantitative/qualitative methods, as the ETIC/EMIC perspectives, the signs and symptoms, are orthogonal dimensions required to understand, so decipher reality as offering facts and meanings. However, in her process of scientific construction, the nursing has chosen to oppose the differential qualitative fundamentalism versus biomedical quantitative orthodoxy.  And although it is logical, it is still disturbing and counterproductive.  After all, doctors and nurses have in common, against most of the sciences, the same object of study there isn´t the regularity but the singularity of the disease and the individual. Health research methodology shouldn´t be done with qualitative methodology for being nurse or quantitative for being biomedical, but must be indebted to the investigation subject. The facts are quantifiable, but not their signification. And both are two sides of same coin, dimensions of reality to which we can only approach from a proper perspective: to the facts quantitatively, qualitatively to their significance.
Key-words: Paradigm/ Qualitative research/ Quantitative research/ Methodology/ Nursing research.

Qualitative vs. Quantitative research: differences and inferences

     The aim of any science is the acquisition of knowledge, so choosing the right method that allows us to know the reality will be fundamental.¹ In this sense, inductive and deductive methods have different objectives and could be summarized as developing theory and analysis of theory, respectively. Inductive methods are generally associated with qualitative research, while deductive method is often associated with quantitative research. The fundamental difference between scientific method is that one studies the association or relationship between quantified variables and the other do it in structural contexts situacionales.² Cook and Reichardt³ associated the quantitative perspective with positivism, with measurable and objective, with reliable with repeatable and generalizable data, and qualitative phenomenology, with the observation and subjective, with prolific and authentic data, but not widespread.
     Furthermore, Guba says that "the naturalistic approach aims to develop knowledge idiographic, focusing on differences between objects, as often and with so much interest in the similarities",⁴ so that while the rationalists have preferred quantitative methods, the naturalists have preferred to qualitative methods. According to this author, rationalists believe that the most important criterion for measuring the quality of research is the "rigor" (internal validity: "no matter what you do, do it as well"), while for the naturalists is the "relevance" (external validity, "something not worth doing at all is not worth doing well", which despite its romantic aura involves not unrealistic). In regard to the applicability of the research, the rationalist will search for his external validity in terms of "generalizability" while the naturalist will do in terms of "portability".
     The most obvious differences between both methods are shown in Table 1, developed by Pita and Pértigas⁵ based on different authors proposals.^6,7 However, after these methodological differences, which could be considered complementary rather than antagonistic, can be inferred ideological chasm of the rationalist/positivist that support a single reality and naturalists who have multiple realities. In words of Guba, "this bias is so strong that the conflict between the two paradigms is often confused with the conflict between quantitative and qualitative methods, a logic error" because "these two dimensions are orthogonal, there is no intrinsic reason why can´t  accommodate both paradigms and methodologies being developed by both".⁴ And this is because, beyond ideological orthodoxy, both are scientific methods and, as such, have advantages and limitations as shown in Table 2, adapting itself to that reported by Mendoza Palacios.⁸

Historical Perspective on Health Sciences

     Works published by Conde⁹ and Sarrado et al.¹⁰ based on similar premises and reaching conclusions related, develop an overview of the history of Medicine with parallel approaches: one from the ambivalence of the signs and symptoms and the other from the epistemological dichotomy. To Conde, "the historical analysis reveals how the complex double way of signs and symptoms is equivalent to the complex relationship between qualitative and quantitative perspective". The quantitative approach would be signs and symptoms to the more qualitative relations between the two would be similar to those that occur between these two perspectives in the field of Social Sciences. Based on the definition by Noguer and Bacells, why "the <symptoms> are defined as the subjective data, in other words, the sensations that the patient experience and shows us (...), and <signs>, meanwhile, are characterized as abnormal objective findings, somatic (organic or functional)",¹¹ the author considers that such characterizations speak for themselves "on the above qualitative and quantitative paradigmatic orientation of the approach through the <symptoms> and through the <signs> respectively", represented by perpendicular axes (see Figure 1).
     For the ideogram that appears successful, we believe that it could also be a similar parallel, without leaving the qualitative paradigm, from the perspective ETIC (as observation of signs) and EMIC (as an expression of symptoms). In fact, the 'cultural materialism' of Marvin Harris defines these concepts so that Emic is the meaning and sense that things have for the subject, which is not observable since it is on your mind, sculpted by the culture and their own experience. It is their subjective meaning, while Etic is the meaning and sense to the observer. It is external, what the investigator called explorer alien, the observed fact. Of course, both approaches should be supplemented to discover a total knowledge. The investigator must know Emic and Etic perspectives, and not only in Anthropology.
     Not until the XIX century to be developed in parallel two dominant perspectives in the field of health: the classic linked to the disease and its cure and the ultimate in hygiene and prevention. The latter will find in the statistical and epidemiological studies in one of his most important tools in addressing public health. While recognizing the role of statistics, Fleck¹² highlights the uniqueness of the Health Sciences noting how, unlike the natural sciences with the study of the regularities of their screening criteria, the study does not address the regularity but on the contrary, to what is deviant, that is, the disease state.
     In the second half of the XX century, a qualitative research methodology reemerged as a front line, mainly in the US and UK. Over the next decade placed to Sarrado et al the emergence of Medical Anthropology (now called Anthropology of Health and Disease) in various universities of US.¹⁰ This critical movement argues that the assumptions and theories we use do not come falling from the sky, but are formulated, tested, evaluated and accepted by individuals who have common values, ideology, and biography.
     Today, the emergence of HIV-AIDS and other diseases has led many contemporary authors to question the notion of risk groups, epidemiologic root, and a change of "<patient/subject> to <stakeholders> and <subject> (...) that produce social discourses and collective behavior that can be investigated qualitatively".⁹ From the other trench, points to the need for further probabilistic models in evaluating medical research. These include methods based on Bayes theory, which "are close to know the probability that the events are in a certain way depending on what is observed in reality".¹³ For Sacket et al. this stream-based in probabilistic models is connected with the practice of evidence-based medicine (EBM),¹⁴ to use the available scientific evidence in making clinical decisions.¹⁵ It is true that the current paradigm in human sciences, called postpositivist, used overwhelmingly quantitative methodology and the scientific method, maximizing the handling of assigned variables and trying to establish this cause-effect relationships. As is that in hermeneutic and critical paradigms, cultivated in health sciences mainly by nurses, predominantly methodology "qualitative dialogical and dialectical construction".¹⁰
     However, collecting proposals from many different authors,^8-10,16-19 we are positioned in the defense of methodological complementarity based on the arguments presented in Table 3, meaning that "good decision (well technically correct) should fit with the view that the particular person is about right and the way she chooses to live his life".²⁰
     This would not cause much of a new leap in biomedical science pendulum from the quantitative to qualitative, but on the contrary, understanding the complexity of health phenomena in need of both methodologies, "methodological pluralism, can certainly enrich medical science and improve health standards of the population, after all, is what it is".⁹

A nurse critical perspective

     It is unacceptable for the positivist axiom that the phenomena can be reduced to its constituent parts. This means that the whole is equal to the sum of the parties when the human nature itself shows us the opposite day. For Jan Christiann Smuts, South African political philosopher and pioneer of holism, "body, mind, spirit, personal history, values, emotions, culture, aspirations, attitude towards life, temperament, way of relating, society...", all influence health and disease.²¹
     But if we delve into the methods used in qualitative research, we can see that too often uses quantitative analysis techniques. Statistics plays a role in the form of categorization and encoding and even software packages for data processing (Ethnograph®, Aguad®, Nudist® or Atlas-Ti®) are absent in the actual realization of any paper, as recognized Amezcua and Gálvez Toro.²²
     As mentioned, in Health Sciences, nursing is the discipline involved in the development of qualitative studies, possibly linked to the fact of experiencing human suffering on a daily custom. This is a consequence of the holistic concept of care that is based on the nursing profession, a concept first defined in 1926 by Smuts ("Holism and evolution") and disseminated in our country by figures like Marañón or Laín Entralgo. "We must pay attention not only to the data and signs, but the experience of the disease by the patient and family", said last one.²³
     The researchers still scarce, from the medical field, argue the merits of the qualitative approach believe that there is now overwhelming predominance of the quantitative method. To demonstrate this, epidemiologists to Juan Canalejo Hospital of A Coruña (Spain) objectified in the Medline search using keywords quantitative research versus qualitative research, the discovery of 11,236 items and 1,249 respectively, resulting in a ratio of 8.99. When added to the search word to focus nursing to talk about nursing jobs, objectified that the ratio of qualitative vs. quantitative articles (610 to 535) decreased to 1.14, showing both a significant weight of the qualitative research nurse.⁵ Posts to play if you perform a Google search for pages in Spanish with the phrase "qualitative research in nursing", found 193,000 entries, 112,000 if the phrase is "quantitative nursing research", with a ratio of 1.72 now in favor of qualitative research. But if further refine your search to pages published only in Spain, this ratio increased to 1.88 (99,600 per 52,800, respectively). But what happens in the rest of the world? What gives us the most universal form if we perform the search in English? For a really bleak ratio of 9.43 (4.52 million results in 0.20 seconds for nursing qualitative research versus 479,000 by 0.30 seconds for nursing quantitative research) [visited on August 25, 2010].
     As pointed out by De la Cuesta Benjumea, "since the last decades of the last century qualitative studies have proliferated in the area of health, in particular in Nursing".²⁴ In the review it is conducting published in this field, the author finds a variety of methods, with three most commonly used: Ethnography, cultural anthropology debtor and participant observation are looking for categories and cultural patterns, the Grounded Theory,²⁵ derived from Mead´s symbolic interactionism which uses interviews and participant observation, prioritizing the point of view of actors to capture the changes and their effects, and phenomenology in two models: the eidetic or descriptive and hermeneutic or interpreted, taking the first aimed at describing the meaning of an experience and an second to understand experience, so that the main difference between the two is that the hermeneutics, the most commonly used in nursing, requires the presence the researcher in the context in which the interpretive process occurs.
     So, as we have seen, the majority of nursing research has followed the model of qualitative research because, to our knowledge, the scientific and academic researchers and the pursuit of their own epistemological niche in the field of Sciences Health and a distinctive identity with respect to quantitative biomedical research. In the search for differentiating this identity, the absence of Degree led to an anthropological perspective of care. However, the holistic approach, the transcultural and qualitative techniques, even though contributions of great value, are not the only way to investigación.²⁶ Virginia Henderson already pointed it out to see how the research nurse was too polarized to sociological aspects of care, which opposed the need to focus on clinical research that medicine and other disciplines had achieved their greatest successes and knowledge.
     In addition, the universal practice evidence-based nursing is urgent and necessary as it is known that: (a) 20-25% of the cares that are unnecessary or potentially apply harmfuls.²⁷ (b) 30-40% of patients do not receive care consistent with scientific evidence.²⁸ As examples we can point to it, including:
     -Hand washing with respect to which Simmons was a sense giving effect to 90% compared to the actual frequency <30%. Although Voss and Widmer calculated that, if an ICU nurse following strictly the recommendations, about 20% of the working day would clean hands.
     -Heparinization peripheral catheters is widespread in many hospitals with added risk and cost, without having been able to show significant advantage over washing with saline.²⁹
     -The widespread introduction of needleless intravenous connectors (safety valves) in a large hospital, without a "proper education to strengthen the follow the instructions given by the manufacturer, has been associated with outbreaks of bacteremia",³⁰ probably due to that 31% of nurses forget to disinfect the connection before accessing the catheter³¹ and only 33% disinfect the access and wait long enough to evaporate before use.
     In the current framework, with the Nursing Degree and the presentation of Doctoral Thesis made by nurses who are a challenge and an impetus to research in care, the conditions are ideal for the healthcare industry to gain a firm commitment to the research nurse such as pharmaceutical industry bought it long ago with biomedical research. We can´t enter in hospitals and patient care products or technologies backed only by small observational or in vitro studies. The safety and cost/effectiveness of medical devices should be evaluated by clinical trials, consistent with a profession that applies interventions based on scientific evidence.
     As shown by recent experiences,³² it is a perfect match since the nursing needs of the industry's financial support for the development of its research and the industry needs nursing for rigorous scientific studies that endorse criteria of suitability, safety and cost/effective investment in new technologies and medical devices.
     An investigation can´t be done with qualitative methodology as a nurse or to be quantitative biomedical, but the method of choice should be liable for the object of research: quantitative if you measure the impact of a particular technique or product in the survival free of adverse events; qualitatively if one seeks to know the impact on the perceived quality of life for the patient undergoing the technique/product. In words of Mendoza Palacios, "in an investigation is not appropriate to talk about qualitative paradigm, qualitative or quantitative research methodology", as if we were talking about conflicting ideologies, "as are the qualitative or quantitative research approaches, and both can be used in the same research methodologies interacting".⁸ In short, so incongruous and impoverishing that biomedical research is qualitative techniques despise, like nursing back to experimental research.

Final thought: questionable axioms generate complementary methods

     In fact, as maintained by epidemiologists everything is quantifiable, even in qualitative research. Something as subjective and subject to the culture and experience that each has the pain is measurable and it is done in clinical practice, using the analog scale of pain when administering analgesia. However, if in fact we should know is how the same degree of pain on the analog scale affects two different patients, the extent to bankrupt their physical, psychological and emotional disabilities, we have to resort again Emic perspective to, the symptom expressed by the subject, the use of qualitative techniques and the results will tend to quantify but can´t be extrapolated to generalize because it truly is the method, not its result. This is because "things are not meant" as claimed by the followers of symbolic interactionism.³³ Although certainly not an axiom is extrapolated to all areas (Is the hunger and thirst of the Third World are either are mean or mean but not the same for everyone?), it is true that there are situations, such as loss of a loved one, where the standard lies in its meaning beyond the actual fact.
     Giving a final twist might wonder how to deal exclusively from the biomedical paradigm phantom limb pain. Then we must admit that, in medicine, "is real what the person defines as real"³⁴ but it yourself and put it centuries ago the greek philosopher Epictetus, saying that human events affect and are therefore not in itself but the valuation of them do. Therefore, it will be recognized because those charged with the biomedical paradigm critics who claim that "the theoretical affiliation of the author acts as a mask that emerges when he tells his version of events",³⁵ but without forgetting that this is generalizable to any paradigm, since "qualitative approach to health problems is not just an option (...). As is seen, is a researcher's commitment to the society whose interests are supposed to serve, but that technological progress does not always guarantee".³⁶ And, as has been said, humans, researchers or not, we are indebted to our own biography.
     Put it this way: the facts are quantifiable, but not their meaning. But both, fact and meaning are two sides of the same coin, dimensions of reality to which we can only approach in perspective: facts quantitatively, qualitatively their meanings. Because, to paraphrase Ortega y Gasset, the only wrong perspective is the unique perspective.

Table 1. Differences between qualitative and quantitative research(⁵⁾

Table 2. Advantages and limitations of quantitative vs qualitative methods(⁸⁾

Table 3. Arguments in favor of methodological complementarity(^8-10,16-19)

Figure 1. Paradigmatic axes of quantitative/qualitative outlooks by Conde(⁹⁾

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