Understanding qualitative research and its value in healthcare
VOL: 103, ISSUE: 8, PAGE NO: 32-33
Dawn Brookes, BA, MAEd, RGN, is
Community matron, Ilkeston Health Centre, Ilkeston.
This article places qualitative research in an historical context and explores the issues of rigor and validity of this method.
ABSTRACT Brookes, D. (2007) Understanding qualitative research and its value in healthcare. www.nursingtimes.net.
Qualitative research methods have become increasingly popular in healthcare research in recent years, as can be seen from the increasing numbers of papers published in the medical and nursing literature that have used this methodology. However, there are issues about the quality of the data produced and how this can be improved. This article places qualitative research in an historical context and explores the issues of rigor and validity of this method.
Researchers have fiercely debated the relative merits of quantitative versus qualitative methods of research (Holloway and Wheeler, 2002) and proponents from both sides of the debate have been accused of being separatist and defensive (Murphy et al, 1998; Darbyshire, 1997). Some authors recommend mixing the two research approaches in certain situations (Gillies, 2002) in order to generate quantifiable data, while at the same time probing deeper with a qualitative approach to make sense of the possible reasons behind the data. For example, a study could be carried out to quantify the number of times a nurse prescribes and a qualitative element could be included in order to find out the reasons for those decisions. Combining the two approaches is likely to be more valuable in this type of study than using either in isolation.
A problem of definitions?
Some of the problems with research are concerned with the use of language, terminology and definitions. Terms used to describe qualitative research include interpretive, naturalistic, constructivist, emancipatory, field research, case study approaches (Holloway and Wheeler, 2002) and ethnography (Hammersley and Atkinson, 1995). These different definitions can be confusing for healthcare professionals who want to understand qualitative research.
As healthcare professionals explore the medical and nursing literature for evidence to support and develop their practice they need to be able to understand research methods. Using language that is difficult to understand can make this process complicated and readers may fail to engage with the research. Gillies (2002) suggests that complex terminology can be off-putting, but there is general agreement that it is the themes and characteristics that emerge during the process of conducting qualitative research which are important, and it is these, rather than any complex terminology, that define qualitative research (Holloway and Wheeler, 2002; Polit et al, 2001; Patton, 1990).
Holloway and Wheeler (2002) stressed that qualitative research has its roots in philosophy and human sciences. They suggest that the sociologist Max Weber influenced the development of the ethnographic research methods (the study of human behaviour within a culture). He is regarded as one of the founders of sociology, famed for his comparative and historical studies of large-scale social institutions and was an advocate of the qualitative approach (Magnusson, 1990). Most early qualitative research was dominated by ethnographic and participant observation studies (Grbich, 1999). These were often longitudinal and largely considered unsystematic and unscientific (Holloway and Wheeler, 2002). Although there is evidence of rigorous data collection (Grbich, 1999) they are criticised for pooranalysis and design (Holloway and Wheeler, 2002).
Polit et al (2001) described the strong research tradition that emerged from the grounded theory developed by sociologists Glaser and Strauss (1967), the purpose of which is ‘to generate comprehensive explanations of phenomena that are grounded in reality’ (Polit et al, 2001). Grbich (1999) suggested that from the mid-1960s qualitative research has been characterised by a vast diversity of approaches and continuing debate and change. Particular attention has been paid to the role of the researcher and the rigour of data collection. Following this there has been a growth in qualitative research and numerous textbooks detailing different qualitative methodologies are now available.
Qualitative research in healthcare
Nurse researchers adopted qualitative approaches before the medical profession and comparisons have been made between the philosophy underpinning nursing care and that of the qualitative researcher. Nursing is made up of a number of elements including commitment and patience, understanding and trust, give and take, flexibility and openness (Holloway and Wheeler, 2002). Qualitative researchers would argue that these descriptions could be applied to qualitative approaches (Polit et al, 2001; Munhall and Oiler-Boyd, 1999). Despite this many nurse researchers are employed to collect data on behalf of researchers carrying out quantitative studies (Medical Research Council/British Heart Foundation Collaborative Group, 2002). However, in recent years, increasing numbers of qualitative studies have been published in the medical and nursing press (Harding and Gantley, 1998) and are adding to the knowledge base of these professions.
Qualitative research is able to capture the client perspective of healthcare, and to enable professionals and providers to understand how clients perceive health services (Bryman, 2001). As a result, the growing body of published research in this area is now used to influence health policy at a local and national level.
Qualitative approaches are necessary in primary healthcare when researchers want to ask questions about why patients and healthcare professionals behave in a particular way and to focus on participants’ feelings, meanings and experiences (Bowling, 2002; Greenhalgh and Taylor, 1997). For example, quantitative researchers can explore patient concordance by measuring how many patients are not concordant with a given treatment or prescribed medication. However, this in itself does not help improve concordance, but simply highlights the extent of a problem. Qualitative research aims to explore why it is happening and this may generate ideas to help solve the problem.
The emergence of this qualitative research in primary healthcare has been gradual, with some authors working to educate the medical profession in particular, about the values of such research methods (Mays and Pope, 2000). As a result, qualitative research has come under intense scrutiny and has been harshly criticised. Isbister (2000) in a letter to the British Medical Journal suggested that ‘quality in qualitative research is a mystery to many health service researchers’. It may be that the author was expressing his own bias but in order to convince medical and nursing researchers and funding organisations of the validity and quality of this research the criticisms have been addressed.
Rigour in qualitative research
Barbour (2001) argues that ‘the question is no longer whether qualitative methods are valuable but how rigour can be assured or enhanced’. Some of the criticisms aimed at qualitative research, and in particular at the grounded theory approach, are concerned with the ‘iterative’ approach that involves adapting research methods as the data-gathering generates new information during the process of the study. Researchers have been accused of ‘moving their goalposts’ (Greenhalgh and Taylor, 1997) and Britten et al (1995) warned that this could result in a lack of focus as researchers become unclear about what they are investigating. However, Lincoln and Guba (1985) argued that an emergent design used in grounded theory is not due to a lack of attention or focus. Rather, researchers want to base their inquiries on realities and viewpoints of those being studied, and these might not be apparent at the outset of the study.
In reality, the purest form of grounded theory approach is unlikely to attract funding without researchers formulating an idea of the data likely to be collected beforehand (Barbour, 2001). Others agree that most researchers should use a variant that enables them to identify new themes from the data along with those anticipated at the beginning (Miller and Dingwall, 1997).
Poses and Levitt (2000) warned of problems resulting from an ‘antirealist’ viewpoint, where some qualitative researchers believe that social reality independent of the observer does not exist. They argue that such researchers are in danger of creating methodological anarchy because some claim that rigour is irrelevant to their type of research (Henwood and Pidgeon, 1992).
Checklists of design methods and analysis have been introduced in an attempt to improve the rigour of qualitative research (Pope et al, 2000; Greenhalgh and Taylor, 1997). Barbour (2001) argued that if they are imposed too rigidly checklists may be counterproductive, resulting in them defining the research. However, checklists have improved the acceptability of qualitative research and as such have had a positive impact on its use in healthcare research. At the same time, it is important to recognise the value of research that generates data, and while there is a need to improve rigour it is important to maintain the core values of the qualitative research philosophy.
To improve rigour in qualitative research methods it has been suggested that researchers need to identify a research question (Holloway and Wheeler, 2002; Gillies, 2002; Greenhalgh and Taylor, 1997). Studies that do not do this inspire little confidence.
Triangulation has been identified as one way of helping to obtain rigour in qualitative research studies. The term refers to the use of more than one method of data collection and can involve triangulation of data, investigators and theories (Holloway and Wheeler, 2002). Table 1 explains what each of these methods means and their advantages and disadvantages.
Different groups, for example old and young. Times for example, night/day. Location, for example, hospital, home
More than one researcher
Qualitative and quantitative combined
Different methods of data collection. Can be across paradigms, for example quantitative and qualitative research, or within the same paradigm
Looks at a problem in different ways and from different angles
Helps remove investigator bias. Helps maintain focus
May strengthen the study. Gain a variety of information
May lead to comparable results. Enriches data
Lack of time in student projects to involve more than one person
Differences in sampling, analysis and outcomes.
This may be because of lack of time or smaller numbers used for qualitative research
Inconsistencies may occur. Investigator may be inexperienced with using different methods
Table 1. Triangulation methods
Some authors feel that researchers should stay within one paradigm and argue that qualitative and quantitative methodologies come from different philosophical backgrounds and as such should remain separate (Weaver and Atkinson, 1994). Indeed the argument is not only confined to mixing research methods across paradigms but also to different data collection methods within the same paradigm. However, most nurses and doctors tend to take a more pragmatic view and carry out research across paradigms (Holloway and Wheeler, 2002).
Multiple coding is another way in which researchers try to improve rigour in qualitative research (Barbour, 2001). This involves independent researchers cross-checking coding, and aims to reduce subjectivity in processing the data analysis. Software packages are now available to help process the analysis once coding has taken place (Pope et al, 2000).
Respondent validation is popular with qualitative researchers (Barbour, 2001). This involves cross-checking findings with respondents, and can help to refine explanations. Some researchers point out that this can lead to discrepancies because the researcher would provide an overview of what respondents have said, whereas individual respondents have their own individual concerns (Mays and Pope, 1996).
Qualitative research is growing in popularity in healthcare and particularly in primary healthcare. Much has been done to improve the rigour of this methodology, but there is still considerable disagreement among researchers about how this can be achieved. This disagreement can add to the confusion that many people experience when they try to understand the process of qualitative research. The arguments will continue among those who consider themselves purists and who adhere to an underlying philosophy of one paradigm or another. Others will carry out this very valuable research in a manner that ensures it is taken seriously by the scientific community and therefore may help to improve patient care. A lack of understanding of qualitative research may lead to poor quality studies being published in the medical and nursing literature (Mays and Pope, 2000).
There is a wealth of knowledge to be gained by using the rich data provided by qualitative research and it is therefore important that nurses and doctors persevere in understanding the approach.
Barbour, R.S. (2001)Checklists for improving rigour in qualitative research:a case of the tail wagging the dog? British Medical Journal; 322: 7294, 1115-1117.
Bowling, A. (2002) Research Methods in Health: Investigating Health and Health Services (2nd ed). Buckingham: Open University Press.
Britten, N. et al (1995) Qualitative research methods in general practice and primary care. Family Practitioner; 12: 1, 104-114.
Bryman, A. (2001) Social Research Methods.Oxford: University Press.
Darbyshire, P. (1997) Qualitative research: is it becoming a new orthodoxy? Nursing Inquiry; 4: 1, 1-2.
Gillies, A. (2002) Using Research in Primary Care. Abingdon: Radcliffe Press.
Glaser, B., Strauss, A. (1967) The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine.
Grbich, C. (1999) Qualitative Research in Health: An Introduction.London: Sage.
Greenhalgh, T., Taylor, R. (1997)How to read a paper: papers that go beyond numbers (qualitative research).British Medical Journal; 315: 7110, 740-743.
Hammersley, M., Atkinson, P. (1995) Ethnography: Principles in Practice (2nd ed). London: Tavistock.
Harding, G., Gantley, M. (1998) Qualitative methods: beyond the cookbook.Family Practice; 15: 1, 76-79.
Henwood, K., Pidgeon, N. (1992) Qualitative research and psychological theorising. British Journal of Psychology; 83 (part 1): 97-111.
Holloway,I., Wheeler, S. (2002) Qualitative Research in Nursing (2nd ed). Oxford: Blackwell.
Isbister, W. (2000) Good communication is an essential part of the educational process. British Medical Journal; 320: 7251, 1729.
Lincoln, Y., Guba, E. (1985) Naturalistic Inquiry.California: Sage.
Magnusson, M. (ed) (1990) Chambers Biographical Dictionary. Edinburgh: Chambers.
Mays, N., Pope, C. (1996) Rigour in qualitative research. In: Mays, N., Pope, C. (eds) Qualitative Research in Healthcare. London: British Medical Journal Publishing.
Mays, N., Pope, C. (2000) Qualitative research in healthcare: assessing quality in qualitative research. British Medical Journal; 320: 7226, 50-52.
Medical Research Council/British Heart Foundation Heart Protection Study Collaborative Group (2002) MRC/BHF Heart protection study of cholesterol-lowering with simvastatin in 20536 high-risk individuals: a randomised placebo-controlled trial.The Lancet; 360: 9326, 7-22.
Miller, G., Dingwall, R. (eds) (1997) Context and Method in Qualitative Research. London: Sage.
Munhall, P., Oiler-Boyd, C. (eds) (1999) Nursing Research: A Qualitative Perspective (3rd ed). New York, NY: Appleton.
Murphy, E., et al (1998) Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment; 2:16, iii-ix.
Patton, M. (1990) Qualitative Evaluation and Research Methods.London: Sage.
Polit, D. et al (2001) Essentials of Nursing Research: Methods, Appraisal and Utilisation (5th ed). Philadelphia, PA: Lippincott.
Pope, C. et al (2000)Qualitative research in healthcare: analyzing qualitative data. British Medical Journal; 320: 7227: 114-116.
Poses, R., Levitt, N. (2000) Antirealism is an excuse for sloppy work. British Medical Journal; 320: 7251, 1729-1730.
Weaver, A., Atkinson, P. (1994) Miscomputing and Qualitative Data Analysis. Aldershot: Avebury.
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