Qualitative research paradigms offer a perspective to explore and understand human behavior that arises from a different philosophy than quantitative research designs. Quantitative methodology is linked to the philosophy of logical positivism, in which human experience is assumed to be limited to logical and controlled relationships between specific measurable variables. The rationale for studying these relationships can be defined in advance, based on hypotheses that guide the methods of inquiry. Accordingly, variables can be operationalized and assigned numerical values, independent of historical, cultural or social contexts within which performance is observed.46 For example, many quality of life assessments, by virtue of their list of questions, are based on assumptions about measurable behaviors that reflect health status. By using a single rating scale for all subjects, investigators demonstrate the reductionist premise of quantitative research: that experience and clinical phenomena can be reduced to a set of specific questions and variables predetermined by the researcher.
The essence of the qualitative method, on the other hand, obliges the researcher to understand the person's perspective first. Qualitative research seeks to describe the complex nature of humans and how individuals perceive their own experiences within a specific social context. Qualitative methodology uses the subject's own words and narrative summaries of observable behavior to express data, rather than numerical data derived from predetermined rating systems. The qualitative approach emphasizes an understanding of human experience, exploring the nature of people's transactions with themselves, others and their surroundings. Qualitative designs and methods also allow the study of many simultaneous variables contained in a phenomenon. Questions that lend themselves to qualitative inquiry are generally broad, seeking to understand why something occurs, what certain experiences mean to a patient or client, or how the dynamics of an experience influence subsequent behaviors or decisions.47
For example, Carpenter48 explored the experience of a spinal cord injury (SCI) with individuals who had sustained such an injury. This work demonstrated that the education about living with SCI provided by health care professionals did not match the lived experience of those with the injury, suggesting the need to transform educational approaches. The qualitative investigation into this phenomenon helped to uncover the meaning of SCI to those who experience it, and how it affects their behavior, emotions, body image, self-esteem and interactions. The purpose of qualitative inquiry is to examine such experiences using a holistic approach that is concerned with the true nature of "reality" as the participants understand it. Qualitative methodology has been a cornerstone of research in sociology and anthropology and has more recently received attention by clinical researchers.49,50
The need to understand the patient's view of the world is particularly important with the widespread adoption of principles of evidence-based practice, which compel the practitioner to consider the patient's values and circumstances in combination with clinical judgment and evidence from the literature. Qualitative designs are well suited to explore patients' preferences, giving practitioners the opportunity to understand the concepts of health, illness and disability from the direct perspective of the person who lives it.51,52,53
Combining Qualitative and Quantitative Approaches
Qualitative research is not just a description of a particular situation. To qualify as a research method, such inquiry must be tied to understanding, explaining, or developing theory about an observed phenomenon. From such insightful description, relevant variables can be uncovered, and questions can then be posed to study quantitative aspects of those variables in controlled settings. Qualitative and quantitative aspects can also be combined within one study to measure certain components of behavior and to see how such measurements relate to the nature of the actual experience.54 Use of both qualitative and quantitative methods in the same study can increase the validity of the findings.55
For example, Talion and colleagues56 used a focus group of patients with osteoarthritis of the knee to design a questionnaire that exposed a mismatch between treatment priorities of patients and those of health care practitioners. Hayes et al57 used both a descriptive questionnaire and qualitative interviews to better understand clinical instructors' perspectives of problematic student behaviors. Paterson et al58 used both semi-structured interviews and standardized outcome tools to measure the outcomes of a program of massage in patients with Parkinson disease. The two approaches were used together to identify difficulties with the standardized tools and specific perceptions of the participants not available in those tools. Because of the richness of the combined data, the authors were able to recommend several very specific features for future research.
Perspectives in Qualitative Research
There are a number of different approaches one may take when using a qualitative research design. These include phenomenology, ethnography and grounded theory.59 These methods are considered naturalistic inquiry because they require substantial observation and interaction with subjects in their own natural environment.
The tradition known as phenomenology seeks to draw meaning from complex realities through careful analysis of first-person narrative materials.60 The researcher begins this type of inquiry by identifying the clinical phenomenon to be studied. Illness, physical disability and childbirth are examples of phenomena that have been explored by health professionals. Within the phenomenological perspective, experience is constructed within the individual's social context and is, therefore, intersubjective.61 As an example of this approach, DeGrace62 studied the meaning of a family's experience of daily life with a child with severe autism. Her results showed that the family had difficulty engaging in daily activities that held positive meaning for them, and that they relied on stringent routines that revolved around the child to meet daily life demands.
In a phenomenological study in the workplace, Blau and colleagues63 describe the responses of physical therapists to major changes in the healthcare system in which they practiced. They identified four common themes related to stress and discontentment, but also identified that participants were able to find positive affirmation in their work. In a similar study, Dale et al64 investigated the influences of cost containment constraints on occupational therapists in a hand therapy clinic. They found that the therapists modified their skills, their professional settings, and implemented innovative interventions to function effectively.
A second common perspective, called ethnography, is the study of attitudes, beliefs and behaviors of a specific group of people within their own cultural milieu.65 In ethnographic studies, the researcher becomes immersed in the subjects' way of life to understand the cultural forces that shape behavior and feelings. Questions often emerge as data are collected. The ethnographer begins this type of inquiry by identifying the setting or culture to be studied and may specify the types of phenomena that will be observed. Classic examples of ethnographic research are found in the well known anthropological works of Margaret Mead.66,67
This approach has been used to study the traditional beliefs and practices related to pregnancy and childbirth among Native American women.68 Swigart and Kolb69 interviewed sheltered and street-dwelling homeless persons to describe factors that influence their decisions to utilize or reject a public health disease-detection program. Wingate et al70 studied the perceptions of activity and vocational status in women with cardiac illness. As these examples illustrate, the concept of culture in ethnographic research is taken broadly.
Qualitative research has also expanded to include the concept of research synthesis through the use of meta-ethnography. This approach uses analysis of multiple sources to develop new insights into the phenomenon being studied. For example, Smith et al71 studied factors that delay a person's willingness to seek help for a potential cancer. Their synthesis of 32 papers was able to identify several factors that delay seeking help, including lack of recognition of the meaning of symptoms, fear, and gender of the patient.
One of the unique features of qualitative methodology is that it allows the researcher to develop theory to explain what is observed. This approach is called grounded theory research, in which the researcher collects, codes, and analyzes data simultaneously. This facilitates identification of relevant variables, and using an inductive process, identification of theoretical concepts that are "grounded" in the observations.72 These concepts are not based on preconceived hypotheses, but instead grow out of an ongoing constant comparative analysis of each set of data collected. As data are gathered and coded, each idea or theme is compared to others to determine where they agree or conflict. At any point in the study, if data do not support the theory, the data are not discarded, but the theory is refined so that it fits the existing data; that is, the theory must come from the data.
As this process continues, interrelationships emerge that lead to the development of a theoretical framework. Data collection and analysis continues until data being collected become repetitious, affirming what has already been identified and no new concepts or relationships emerge. This method requires a sophisticated approach to coding and categorizing data.
A wonderful example of grounded theory research is found in the work of Jensen and colleagues,73,74 who collected and analyzed data over a 10-year period to develop a theory of what constitutes expert practice in physical therapy. Working with recognized "experts" in a variety of specialty areas, they formulated a theoretical model with four dimensions, as shown in Figure 14.3. The theory suggests that these dimensions may exist in the novice practitioner, but not in an integrated manner. They propose that these elements become increasingly integrated as a therapist's competence and expertise grow, moving toward a well-developed philosophy of practice.
Model of core dimensions of expert practice in physical therapy. (From Jensen GM, Hack LM, Shepard KF. Expertise in Physical Therapy Practice (2nd ed). Saunders, St. Louis, 2007, Figure 8-4, p. 168. Reprinted with permission of Saunders Elsevier.)
Methods of Qualitative Data Collection
Because qualitative data can come from a wide variety of sources and can take many different forms, the methods of data collection are also quite varied. The most common forms of data collection are observation and interviews.
Field observation of the phenomenon being studied is often conducted prior to interviews. The purpose of this observation is to identify people, interactions, the influence of sociocultural context and even artifacts that might be studied in depth to acquire relevant data to answer the research question. As a "nonparticipant" in the activities being monitored, the researcher quietly and as inconspicuously as possible simply observes. Immediately following the observation, the researcher records field notes about what was observed and uses memos to capture possible questions for follow-up interviews. Nonparticipant observation sessions can also be videotaped so that later the participants can discuss with the researcher what they were thinking while they observe their own behavior. This technique is used to capture the participant's reality while diminishing the sometimes distorting effects of recall.
The essence of qualitative research is that the individual's experience should be described as it is lived by that individual. Therefore, the researcher can also become embedded within the group, using the technique of participant observation. With this method, the researcher actually becomes a participant in the activities of the group being studied, so that observation of behaviors can be appreciated from the standpoint of those who are being observed. While this technique, as with other research techniques, is inherently biased by the researcher's own preconceptions, it does provide a mechanism to describe the interactions of individuals within a social context and to analyze behaviors as a function of the subjects' personal realities. The researcher is in a position to recognize feelings and thoughts that emerge from the subjects' frame of reference. For example, Hasselkus75 studied the meaning of daily routines and activities at a day-care center for persons with Alzheimer disease, as experienced by the staff. Data collection included interviews and participant-observation, by working directly with the staff. Through this experience, the researcher determined that the foremost guiding principle for all activities during the day was prevention, that is, to prevent participant behavior that would be harmful to self or others. She was also able to identify characteristics of the staff's perception of a "good day" versus a "rough day." Participant-observer is a complex role, but one that is believed to enhance the validity of qualitative observations.76
Interviews involve a form of direct contact between the researcher and the subjects within their natural environment. Interviews are used to gather information, with the researcher asking questions that probe the subject's experiences and perceptions. For example, Monninkhof and colleagues77 interviewed patients with chronic obstructive pulmonary disease (COPD) in their homes. The data obtained was used to explain how and why standardized health related quality of life scales failed to capture accurately the patient's experience. Potter et al78 used structured interviews and a nominal group technique to identify the kinds of patients perceived as difficult by physical therapists, as well as strategies for dealing with them. They identified behavioral problems and patient expectations as leading to the greatest difficulties, with improved communication as the primary strategy. Fogarty79 used focus group interviews to identify the benefits of exercise for patients with schizophrenia who resided in a community care facility. In addition to reported gains in physical status, both staff and participants reported improvement in cohesion among residents and between residents and staff.
Interviews should be approached with a broadly structured script that will guide the discussion and provide a basis for comparing responses; however, they must also be flexible enough to allow the interviewer to probe and ask follow-up questions that are relevant to the specific individual's circumstances. For example, an interviewer might simply ask, "Tell me what it has been like for you to have a spinal cord injury? Such a question is usually followed by additional probes, such as "Can you tell me more about that?" and "Can you give me an example of___?" to elicit the full richness and truth value of the data. This process requires that the interviewer have expertise in the subject matter that will be discussed. This should include prior observations of the participant in his or her natural setting so that the appropriate and relevant follow-up questions will be asked.
The quality of the data collected will depend on the knowledge and skill of the interviewer. Therefore, interviewers should be trained in both interviewing and observation skills, and must be sensitive to the issues that will be raised by respondents.80 While interviews for qualitative research may seem similar to the clinical interview, it is important to remember a fundamental difference. Clinical interviews have as their primary focus to arrive at a diagnostic decision; qualitative interviews are designed to bring about a better understanding of the phenomenon from the participant's perspective.81
Data Analysis and Interpretation
Qualitative data analysis is primarily an inductive process, with a constant interplay between data that represent the reality of the study participants and theoretical conceptualization of that reality. Therefore, the process of analysis is ongoing as data are collected. Because observational and interview responses are recorded as narratives, qualitative data are typically voluminous. Data will usually be recorded through written memos or transcribed from audio or videotapes. The specific techniques of data analysis can vary from purely narrative descriptions of observations to creating a coding system from which categories can be developed, and in a systematic way, patterns or themes develop from the mass of information.82
Analysis of qualitative data by hand involves many hours of sifting through narratives, coding and organizing. There are computer programs that help the qualitative researcher manage the large amounts of data that are typically gathered. The available programs are user friendly and highly interactive and are designed to assist the researcher to record, store, index, cross-index, code, sort and interconnect text-based material.83 There are also numerous programs available which are referred to as computer-assisted software. These are categorized into five main software families which reflect their primary function: text base managers, code programs, retrieval programs, code-based theory builders, and conceptual network builders.84
There is considerable debate in the field of qualitative research about the use of computer programs for data analysis. The debate focuses on the loss of intimacy with the data as well as issues of confidentiality and security of the participants. The key to researchers using these programs is to keep in mind that they are designed only to assist the researcher in managing the data, but not to analyze data, develop theory or draw conclusions about findings. It is of utmost importance that researchers not allow the computer program to direct the interpretive activity.84
Reliability and validity are issues of concern in qualitative research just as they are in all types of research. For qualitative study, the concept of "measurement error" must be examined in terms of judgments rather than numerical equivalency.85 Because the data sources are words rather than numbers, different terms and techniques are used to describe and determine the trustworthiness of the data. Lincoln and Guba86 have suggested the terms "credibility" and "truth" to refer to internal validity, "transferability" to refer to external validity, and "consistency" and "dependability" to refer to reliability. They describe a number of techniques that can be used to increase credibility and consistency of qualitative data. Similar to techniques used in quantitative research, these approaches reflect a need to consider the rigor of data analysis and the potential for investigator bias.
Techniques for Ensuring Trustworthiness of Qualitative Data
Triangulation refers to a process whereby concepts are confirmed using more than one source of data, more than one data collection method, or more than one set of researchers. The concept actually originated as a technical term in surveying, to demonstrate how two visible points could be used to locate a third point. In social sciences, the concept has been adopted to reflect multiple methods or data sources to substantiate an outcome. For instance, a researcher may identify a specific concept through an interview, by direct observation of group performance, and by analysis of written materials. If comparable conclusions are drawn from each method, the internal validity or credibility of the interpretation is considerably strengthened. For example, Galantino and colleagues87 demonstrated that use of exercise groups resulted in positive physical changes, enhanced coping and improved social interactions for a group of people living with HIV/AIDS. They supported the validity of their findings by showing common themes using focus groups, nonparticipant observation and journals.
The validity of findings can also be supported by a clear description and documentation of the thought processes used to interpret data. This process is referred to as an audit trail, allowing those who read the research to follow the investigator's logic. This provides an opportunity for others to agree or disagree with conclusions, and to reconstruct categorizations. In their study of therapists' reactions to changes in the health care system, Blau and colleagues63 transcribed initial and follow-up interviews, used process notes, and other documentation of data reconstruction to carefully document their process of analysis.
Other strategies for improving accuracy include the involvement of more than one investigator to confirm ideas, confirmation of conclusions with the subject of the study through member checks, and analysis until data saturation (no new themes identified) is reached. For example, Jensen et al73 used three non-physical therapist consultants to support their theoretical formulations. Blau et al63 summarized the themes they extracted from their data and mailed them to participants several months later, interviewing them to validate their interpretations. These strategies are important to control for the potential bias in qualitative analysis.
In qualitative research, subject selection proceeds in a purposeful way, as the investigator must locate subjects who will be effective informants, and who will provide a rich source of information.88 Depending on the research question, the researcher may select one of many types of sampling strategies including typical, maximum variation or extreme. Another type of sampling, termed theoretical sampling, is based on the need to collect data to examine emerging categories and their relationships, and not on identifying specific age, gender or other characteristics of subjects.89 In this type of sampling, a few subjects are initially chosen because they belong to a certain group, but further subjects are recruited based on their fit with theory that emerges from the initial data.90
A common misconception about sampling in qualitative research is that all samples are small. Sample size remains an important consideration. Samples that are too small will not support claims of having reached a point of saturation in the data. Samples that are too large will not permit the in-depth analysis that is the essence of qualitative inquiry. Sandelowski91 suggests that determining adequate sample size in qualitative research is a matter of judgment and experience in evaluating the quality of the information collected and the purpose of the research.
We recognize that this brief introduction to qualitative analysis is by no means sufficient to demonstrate the scope of data collection and analysis methods that have been developed. This approach has great promise for generating understanding of health and how it is evaluated. Those interested in pursuing qualitative research are urged to read the references cited in this chapter. We also suggest reading professional literature, such as the journal Qualitative Health Research, to gain an appreciation for the breadth of qualitative research and to develop familiarity with the techniques and terminology of qualitative methodology.