Anna Strömberg, RN, PhD, FAAN, Professor

University of California Irvine, Program in Nursing

Department of Medical and Health Sciences, Linköping university

Department of Cardiology, Linköping university hospital

Gain insights through discovering meanings

Comprehension of the whole, not causalities

Depth, richness and complexity of a phenomena

Is dependent of the context

Researcher is part of an iterative process, but should not influence the informant

Glaser & Strauss 1965 studied ”awareness of dying”

Practice at the time: people should not be told they were dying The health care ”protected” the patient from knowing

This approach created loneliness and isolation

Kübler-Ross studies 1969 "On Death and Dying” five stages of grief: denial, anger, bargaining, depression and

acceptance

Hospice – enviroment for end-of life care changed

• Quantitative method: facts• Describe, quantify

• e.g percentage of men/women, length of in hospital stay, symptoms

• Find correlations and causalities• Uni- och multivariate analysis• Generalisability – random samling

• Qualitative method: understanding • Partly unknown phenomena• Complex phenomena

Qualitative QuantitativeParadigm Naturalistic Positivistic

Design Open, can vary and be altered

Fixed, predetermined

Data Text, narratives, deeper content

Numbers

Sample Small sample Larger sample

Role of the researcher

Closer to the contex, interaction with studysubjects

Neutral

Generalisability Transferability Generalisability

Quality RigourTrustworthiness:• Confirmability

Credibility• Transferability• Dependability

ValidityReliability

Bernard, H. R. (1996). The Cultural Anthropology Methods Journal, 8(1), 9–11.

v

v

Empirics – ”the reality”

Theory

Inductive

Deductive

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(ROBERT FROST 1874-1963)

Two roads diverged in a wood, and I-I took the one less traveled by,And that has made all the difference

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• When the goal is to explore or understand the meaning of a phenomenon

• Research areas:• Lived experiences, perceptions, thoughts,

expectations, motives and attitudes

How do patients' and family members' perceive disclosure of healthcare incidents?

Can patient and family interviews derive principles of effective disclosure?

Iedema R et al. Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study. BMJ. 2011;343:d4423.

What matters to older people with assisted living needs? A phenomenological analysis of the use and non-use of telehealth and telecare.

Greenhalgh T et al. Soc Sci Med. 2013;93:86-94

Identify potential risks and benefits associated with bloggingand determine if social media can play a role in supportingpatients with multi-drug resistant tuberculosis

Horter S et al Plos One 2014;9;e108591

Generate hypothesis

Confirm and deepen quantitative findings

Produce in-depth knowledge before creating an instrument or intervention, a definition, theory or model Develop PROM - instruments developed to mirror the voice of

patients Alternative end-point Quality registries

As part of a mixed method Evaluate complex interventions

Systematic review and meta-analysis of qualitative studies

How do women who are being abused by their partners want their health care providers to react to the disclosure of this abuse?

Feder GS et al. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med2006;166(1):22-37

Early infant male circumcision (EIMC) is simpler, safer and more cost-effective than adult circumcision.

In sub-Saharan Africa, there are concerns about acceptability of EIMC which could affect uptake.

In 2009 a quantitative survey of 2,746 rural Zimbabweans (aged 18-44) indicated that 60% of women and 58% of men would be willing to have their newborn son circumcised.

Willingness was associated with knowledge of HIV and male circumcision.

This qualitative study was conducted to better understand this issue.

Mavhu W et al. Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective. Plos One 2012;7(2):e32475. Epub 2012 Feb 27

Lewin S et al. BMJ 2009;339:b3496

19

Campbell et al BMJ 2000:321:694-696

Phase 1 Item development from a content analysis of the literature and qualitative interviews

Phase 2 Content validity assessment and pilot testing

Phase 3 Field testing, factor analysis, and reliability estimation

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Discipline Research method Area of inquiry

Antropology Ethnography Holistic meaning of a culture, a cultures shared rules, semanticrules

Sociology Grounded theory Social structural processes in a social settingSocial interactions

Psychology/Philiosophy

Phenomenology Experiences of individualslifeworld

Method Focus Sample Size

Ethnography Context or culture --

NarrativeIndividual experience &

sequence1 to 2

Phenomenological

People who have

experienced a

phenomenon

5 to 25

Grounded TheoryDevelop a theory from

grounded in field data20 to 60

Case StudyOrganization, entity,

individual, or event --

Stemming from a theoretical or epistemeological position

Grounded theory Ethnography Phenomenology

Flexible and independent of theory

Content analys Thematic analysis

• Conventional – Inductive– Manifest or latent– Data guide development of categories

• Directed– Deductive– Theory guide development of categories

• Summative – Identifying and summing of key-words

Hsieh H-F. & Shannon S.E. Qualitative health research 2005;15;1277-88, Graneheim U & Lundman B. Nurse Education Today 2004; 24: 105–112

(1) Death as a natural part of life (38%)

(2) Death as a relief from symptoms and disability (13%)

(3) Death as fearful (22%)

(4) Arrangements for time after death (7%)

(5) A wish for an extended life (20%)

Strömberg A & Jaarsma T. Eur J Heart Fail. 2008

Inductively describe emotional reactions of terminally ill patients who are receiving hospice care

Deductive validation of Kubler-Ross five stage of grief (denial, anger, bargaining, depression and acceptance)

The summative occurence of the terms die, death and dying in comparison to euphemisms like passing, going to a better place etc.

Thematic analysis is the most common form of analysis in qualitative research

Themes are patterns across data sets that are important to the description of a phenomenon and are associated to a specific research question

Thematic analysis is performed in six phases : familiarization with data generating initial codes searching for themes among codes reviewing themes defining and naming themes producing the final report

Flexibility - can be applied across a variety of epistemologies

Well suited to large data sets

Great for multiple researchers.

Interpretation of themes supported by data

Allows for categories to emerge from data

Reliability is a concern due to wide variety of interpretations from multiple researchers

Thematic analysis may miss nuanced data

Flexibility makes it difficult to concentrate on what aspect of the data to focus on

Discovery and verification of themes and codes mesh together

Limited interpretive power if analysis excludes theoretical framework

Developed in sociology, symbolic interactionism

Glaser & Strauss 1967

A method to develop new models and theories

Data collection and data analysis is done in parallel“constant comparison”

Saturation

Literature review after development of a new theory

Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press

Interpretation supported by data

Can be used to study topics beyond individual experiencese.g. cultural norms, social processes

Does not include quantification

Time consuming to deal with larger data sets

• Roots in philosophy- Husserl, early 20thcentury

• Many schools

• Lived experience of a phenomenon

• Four steps• “Bracketing”• Narrative reading• Coding• Define essens of the phenomena

…asks for the very nature of a phenomenon, for that which makes a some”thing” what it is and withoutit could not be what it is

Good for smaller data sets

Has latitude to explore data deeply and extrapolatebeyond the text

Focus only on human experiences

May interpret too far beyond data

Not necessarily systematic

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Flexible, evolve as the study progress

Some decision has to be made during design

Seldom strict protocols and forms Form for sociodemographic data Interview questions/guide

Creativity for workable solutions in problematic situations

Research questions/aims

Literature review? • Can be done before or after the analysis

• Pre-understanding and prejudice

N=?

Information-rich cases

Non-probability sampling Convenience sampling Quota sampling to include underrepresented groups, ensure variation

Purposive (judgemental) sampling Most representative or informative participants

Theoretical sampling GT - constant comparative method Emerging findings guide sampling to ensure representation of important

themes “saturate categories”

Network sampling Snowball - referrals from earlier participants

Interview

Observation

Document analysis medical charts, patient diaries

External Participation - lowest degree of involvement. Observing situations on television or videotape.

Passive Participation - researcher is present but does not interact or participate. Role of a bystander or spectator.

Balanced Participation - researcher maintains a balance between being an insider and being an outsider. The researcher observes and participates in some activities, but does not participate fully in all activities.

Active Participation - researcher generally does what others do. While beginning with observation to learn the rules, as they are learned the researcher becomes actively engaged in the activities of the setting.

Total Participation - researcher is a natural participant. Highest level of involvement and usually comes about when the researcher studies something in which he or she is already a natural participant.

Structured unstructuredseminstructured

Unstructured narrative interview with little interference by the interviewer

Level of control

Structured, standardised with exact, predetermined questions asked in the same order

Semistructured open interview with six to eight questions/areas

Polit D & Beck C. Nursing Research. 2012

Ask How did you react? Instead of Where you upset?

Open questions will give good quotations

Open questions begin with Tell me about…How did you…What did you experience/do/think… Can you describe…

Can you describe your experience of living with breast cancer… The diagnosis Time before surgery Hospitalisation after surgery Discharge Out-patient treatment: radiation or chemotherapy Rehabilitation and follow up

Ryan F et al. Int J Therapy Rehab 2006;16:309-14

Individual interview Focusgroups Telephone interviews Repeted interviews

• Information to the participant

• Possible scenario

• Pilot interview

• Place for interview

• Tape recording

• Gain trust

• Be involved, but keep distance

• Debriefing

• The art of active listening

• The art of asking the right questions• Trigger narratives

• Structuring & standardisation• Fixed questions, guide or one open question• Avoid directed, imprecise and general questions• Be open and let the informant have the initiative initially,

be more guiding and reflecting at the end

• Follow up questions• To clarify, develop, deepen

• Can you tell me more about…• Can you explain how you mean…• Previously you said that...

• Be “nagging” at the end...

Exploring question: Can you tell me about your experiences having a myocardial infarction…

Structuring questions: I would not like you to move on to a different topic…

Follow up questions: Could you say some more about that…, What do you mean by….

Probing question: You mentioned feeling angry, can you tell me more about that…

Specifying questions: What did you do then…

Interpreting question: Do you mean that…

“warm up” and closing question

Evaluate with participant

Ask for a later contact for validation of interviews if planned

Offer support/telephone contact

Write notes/memos

Transcribe interviews verbatim

o 24 group discussions were held across Zimbabwe with participants from seven ethnic groups.

o Key informant interviews were held with private paediatricians who offer EIMC (n=2) plus one traditional leader.

o Interviews were audio-recorded, transcribed, translated into English (where necessary)

o For coding NVivo 8 was used

o Data was analysed using grounded theory principles.

Mavhu W et al. Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective. Plos One 2012;7(2):e32475. Epub 2012 Feb 27

Begin analysis during the fieldwork; make notes and memos Inventory and organize data Fill in the gaps in the data as soon as possible Protect the data Reaffirm the purpose of inquiry Make decisions about software Schedule intense dedicated time for analysis Clarify and determine initial analysis strategy Be reflective and reflexive Keep an analysis journal

Code dataFind patternsLabel themesDevelop category systems

Matrix analysisInterpreting findings

Meningful units

Codes

Essence

Theory

Themes- subthemes

Category -subcategory

NVIVOAtlas

Organise and analyse unstructured information Interviews, pictures, sounds, videos

Can handle all Microsoft applications

Transcribe, code, comment, structure the material

Make searches, visualise correlations, analyse

Different user can work jointly Colour coding

Make graphs, tables, reports

Core category Categories Properties

Striving to resume command in one’s life

Economizing resources Restricting oneselfMaking plans

Distracting oneself Avoiding lonelinessSuppressing thoughts

Submitting to one’s fate Becoming dependentSeeking support

Reevaluating life Feeling gratitude for survivingAccepting the ICD

The conceptual model: Striving to resume command in one’s life as emerged from data in ICD recipients, N = 16

STRIVING TO RESUME COMMAND

Economizing one’s resources

Distracting oneself

Submitting to one’s fate

Re-evaluating one’s life

J FAM NURS.

to elucidate the whole family’s experience, from each family member’s perspective, when a child in the family is diagnosed as having diabetes.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Swedish+families%E2%80%99+lived+experience%E2%80%A6%E2%80%A6.+when+a+child+is+first+diagnosed+as+having

Qualitative investigation of patient adherence to 5‐aminosalicylic acid therapy in patients with ulcerative colitis

Qualitative investigation of patient adherence to 5‐aminosalicylic acid therapy in patients with ulcerative colitis

Qualitative investigation of patient adherence to 5-aminosalicylic acid therapy in patients with ulcerative colitis

Tetyana Moshkovska MD1,*,

Margaret Stone PhD2,

Richard Baker MD2,

John Mayberry MD1

Inflammatory Bowel DiseasesVolume 14, Issue 6, pages 763-768, 19 FEB 2008 DOI: 10.1002/ibd.20404http://onlinelibrary.wiley.com/doi/10.1002/ibd.20404/full#fig1

1

Adapted model of 5‐ASA adherence in UC.

© This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party.

Quoting is a process that requires the proper balance between scientific reporting and the taking of artistic license

Quotes are used to: support researcher findings illustrate results illuminate experience evoke emotion provoke response

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New methodology that evolved the last 25 years

Endorse two different perspectives in one study

Strengths and challenges

Researchers/team need to be skilled at both methods

Differnt types of designs

Qualitativedatacollection and

analysis

Quantitativedatacollection and

analysis

Compare Interpretation

Quantitativedatacollection and

analysis

Quantitativedatacollection and

analysis

Qualitativedatacollection and

analysis

Interpretation

Interpretation

Qualitativedatacollection and

analysis

Follow upresults

Develop

EXPLANATORY DESIGN

EXPLORATORY DESIGN

CONVERGENT DESIGN

Categories Qualitative findings (n=15) Quantitative results (n=14)Median (Q1; Q3)

Merged findingsoutcome

Adapting to the caring needs and illness trajectory

The partners were involved in relation to the patient’s’ health situation and needs. The needs varied from being limited to extensive. Partners were involved in personal care, self-care, drug treatment, and practical tasks at home

Performing caregiving tasks:Personal care 1.2 (1.1; 1.6)Motivational care 1.7 (1.1; 2.0)Practical and treatment related tasks 2.5 (2.0; 2.9)

Converge and expand

Mastering caregiving demands

The partners’ willingness to participate in care revealed a span ranging from no will to be involved to being utterly involved. Partners expressed their responsibility and duty to support the patient, reflecting both positive and negative emotions

Overall satisfaction participation in care* 8.0 (7.0; 9.5) Participated to the extent they wanted 4.0 (3.0; 4.0) Perceived too high demands 2.0 (1.0; 3.0)

Expand

Interacting with health care providers

The partners were present during visits, but their activity level varied. They communicated their knowledge and information to the health care professionals who listened and were interested, and discussed the care and treatment.

Participation in care* 11.0 (7.5; 12.0), 92% of max score

Converge

Lewin S et al. BMJ 2009;339:b3496

92

Question-answering process may be complex involving several cognitive steps

Some processes are consious and some automatic

Cognitive interviews reveal information on the process

Verbal Probing Techniques

99

Development of instrument Revision/adaptation of instruments Translation of instruments

100

Literature review questionnaires and patients experiences

Patient interviews

→ Item generation Expertpanel – nurses, patients, phycians

→ Evaluating items (adding/deleting/changingitems)

Initial testing of items and answering alternatives via ThinkAloud interviews

→ Rephrasing Data collection for validation

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If there were only one thruth, one could not paint hundreds of canvases on the same theme.

Pablo Picasso 1966

The findings are “worth paying attention to” (Lincoln & Guba, 1985, p.290).

Four issues of trustworthiness: Credibility - confidence in the 'truth' of the findings Transferability - showing that the findings are applicable in other contexts Dependability - showing that the findings are valid, consistent and could be

repeated Confirmability - a degree of neutrality or the extent to which the findings of a

study are shaped by the respondents and not researcher bias

Traditional Criteriafor Judging

Quantitative Research

objectivity

internal validity

external validity

reliability

Alternative Criteria

for Judging

Qualitative Research

confirmability

credibility

transferability

dependability

In qualitative method the subjective judgement of the researcher is considered an asset. Subjectivity is essential for the understanding of human experience.Polit, D. F. Beck, C. T. Nursing Research. 8th Ed, Lippincott Williams & Wilkins, Philadelphia, 2008

Confirmability is a measure of how well the findings are supported by the data collected. (Lincoln & Guba, 1985)

In-depth methodological description to allow results to be scrutinised

Data audit of decisions made and procedures described Admission of researcher preunderstanding, beliefs and

assumptions Triangulation to prevent investigator bias Testing rival explanations Negative cases Recognition of limitations

Credibility is an evaluation of whether or not the research findings represent a “credible” conceptual interpretation of the data drawn from the participants’ original data (Lincoln & Guba, 1985)

Quality of the research “rigour” Sampling

Data collection

Interviews, observation

Tape recording, transcripts

Established authority of researcher

Data analysis - How well categories and themes cover data. No relevant data have been excluded or irrelevant data included.

The hermenutic spiral

Integrity in the analysis Independent coding → consensus discussion

The whole is build of the parts

To motivate the interpretation of the whole the meaning of the parts need to be interpreted

The interpretation of the parts has to be in conjunction with the whole.

Context -decontext

Triangulation Methods Theory/perspective Analyst

Test the inter- and intra-rater reliability of the coding scheme Co-examiner Level of agreement (65-100%) Cohen’s kappa

Empirical ground Agreement/concordance with ”reality” Check with participants/experts

Accordance with previous research

Transferability is the degree to which the findings of this inquiry can apply or transfer beyond the project (Lincoln & Guba, 1985)

“Generalisability”

Comparison of sample to demographic data

Theoretical or purposive sampling

Rich descriptions

Describe in detail the research context and the assumptions that were central to the research.

The person who wishes to "transfer" the results to a different context is then responsible for making the judgment of how sensible the transfer is

Dependability is an assessment of the quality of the integrated processes of data collection, data analysis, and theory generation (Lincoln & Guba, 1985)

The degree to which data change over time and

alterations made in the researcher’s decisions during the analysisprocess. Evaluating inconsistency during data collection and analysis.

Peer examination Code-recode Dense description of research method allow the study to be repeated

We do not see things as they are, we see things as we are.

Talmudic Saying

To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups).

Comprehensive search in Cochrane, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies.

Seventy-six items from 22 checklists were condensed into a comprehensive checklist with 32 items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting.

Personal characteristics

1. Interviewer/facilitator Which author/s conducted the interview or focus group?

2. Credentials What were the researcher’s credentials? E.g. PhD, MD

3. Occupation What was their occupation at the time of the study?

4. Gender Was the researcher male or female?

5. Experience and training What experience or training did the researcher have? Relationship with participants

6. Relationship established Was a relationship established prior to study commencement?

7. Participant knowledge of the interviewer What did the participants know about the researcher?

8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. bias, assumptions, reasons and interests in the research topic

Theoretical framework9. Methodological orientation and theory What methodological orientation was stated to

underpin the study? e.g. grounded theory, phenomenology, content analysis

Participant selection10. Sampling How were participants selected? e.g. purposive, convenience, consecutive,

snowball

11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, email

12. Sample size How many participants were in the study?

13. Non-participation How many people refused to participate or dropped out? Reasons?

Setting14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace

15. Presence of non-participants Was anyone else present besides the participants and researchers?

16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date

Data collection

17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?

18. Repeat interviews Were repeat interviews carried out? If yes, how many?

19. Audio/visual recording Did the research use audio or visual recording to collect the data?

20. Field notes Were field notes made during and/or after the interview or focus group?

21. Duration What was the duration of the interviews or focus group?

22. Data saturation/redundancy Was data saturation/redundancy discussed?

23. Transcripts returned Were transcripts returned to participants for comment and/or correction

Data analysis

24. Number of data coders How many data coders coded the data?

25. Description of the coding tree Description of the coding tree?

26. Derivation of themes Were themes identified in advance or derived from the data?

27. Software What software, if applicable, was used to manage the data?

28. Participant checking Did participants provide feedback on the findings?

Reporting

29. Quotations presented Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number

30. Data and findings consistent Was there consistency between the data presented and the findings?

31. Clarity of major themes Were major themes clearly presented in the findings?

32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?

Qualitative Methods�- What?Qualitative methodChange of practice due to qualitative findingsQualitative – Quantitative Bildnummer 5Bildnummer 6Bildnummer 7Bildnummer 8Qualitative Methods�- When?The Road Not Taken ��(Robert Frost 1874-1963)When to use qualitative method?PerceptionsLived experienceExplore new experiencesWhy increased interest in qualitative methods in medical researchGenerate hypothesisConfirm and deepen quantitative findings�Bildnummer 18Bildnummer 19Develop instruments� Bildnummer 21Bildnummer 22Qualitative Methods�- howResearch traditions that historically used quantitative methodsBildnummer 25Qualitative analysis can be �divided in two campContent analysisBildnummer 28Conventional -inductiveDeductive analysisDeductive analysisBildnummer 32Thoughts about death in patients with advanced heart failureThree examples of palliative care studiesThematic analysisstrengthLimitationsGrounded TheoryBildnummer 39Bildnummer 40StrengthsLimitationsPhenomenologyPhenomenology essence…StrengthLimitationsBildnummer 47Bildnummer 48Data collection �Data collection planStudy participantsData collectionObservationsBildnummer 54Open questionInterview guide -narrativesDifferent context for the interviewPrepare and introduce interviewsInterviewsTypes of questionsAfter the interviewFocus groups�Data analysisPerspective influence resultsData analysisData analysisData analysisComputer programs for data analysisNVivo Bildnummer 70Bildnummer 71Bildnummer 72Swedish families’ lived experience……. when a child is first diagnosed as having diabetes�Wennick et al. J Fam Nurs. 2006 Nov;12(4):368-89.Bildnummer 74The use of quotations in qualitative studiesBildnummer 76Mixed Methods�Mixed MethodMixed Method designsMixed Method - MultimethodologyConvergent designBildnummer 82Bildnummer 83Exploratory designBildnummer 85Bildnummer 86Explanatory designBildnummer 88Confirm, explain and deepen quantitative findings�Intervention Mixed Method designBildnummer 91Bildnummer 92Qualitative method to develop instrumentsBildnummer 94Cognitive process to respond to a questionBildnummer 96Bildnummer 97Bildnummer 98My journey of instrument development �from ”a near death experience” to fascinationBildnummer 100 Method Bildnummer 102Trustworthiness in �Qualitative MethodsOne thruthtrustworthinessBildnummer 106Objectivity and SubjectivityConfirmability (objectivity)�Credibility (internal validity)The hermenetic spiral/loop�To strenghten credibilityCredibility (internal validity)Transferability (external validity)Dependability (reliability)Bildnummer 114Consolidated Criteria for reporting qualitative studies COREQ 32 item checklistDomain 1: Research team and reflexivity�Domain 2: study design�Domain 2: study designDomain 3: analysis and findings��