Anna Strömberg, RN, PhD, FAAN, Professor Department of Medical and Health Sciences, Linköping university Department of Cardiology, Linköping university hospital 1 . Ontology and paradigm . What is qualitative method . When to use it . How to use it . Data collection . Data analysis . Mixed Method . Instrument development . Thrustworthiness . Reviewing qualitative methodology 2 1 3 . 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 4 2 . 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 5 • 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 6 3 Qualitative Quantitative Paradigm Naturalistic/hermenutic Positivistic Ontology Realism Constructivism Epistemiology Understand Explain Design Open, can be altered Fixed, predetermined Data Text, narratives, Numbers observations Sample Small sample Larger sample Role of the Closer to the contex, Neutral researcher interaction with study subjects Generalisability Transferability Generalisability Quality Rigour Validity Trustworthiness: Reliability • Confirmability Credibility • Transferability • Dependability 7 v v Bernard, H. R. (1996). The Cultural Anthropology Methods Journal, 8(1), 9–11. 8 4 Theory Deductive Inductive Empirics – ”the reality” 9 10 10 5 11 (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 12 12 6 • When the goal is to explore or understand the meaning of a phenomenon • Research areas: • Lived experiences, perceptions, thoughts, expectations, motives and attitudes 13 . To explore the patients' perspectives on long term adherence to physiotherapy treatment for non-specific low back pain. Saner J et al. Musculoskelet Sci Pract. 2018 Dec;38:77-82 This qualitative study was embedded in a randomised controlled trial (RCT) which compared the effectiveness of two types of exercise programme on patients with nonspecific low back pain 14 7 . Explore the lived experience of women with obstetric fistula at Bahir Dar Hamlin Fistula Center, Amhara Regional State, Ethiopia. Animut M et al. BMC Womes Health 2019 Feb 26;19(1):37 15 . To ascertain what meaning individuals attach to perceiving images of their own interior body and how the images and their meanings affect the clinical consultation. BMJ Open 2014;4:e004999. Identify potential risks and benefits associated with blogging and determine if social media can play a role in supporting patients with multi-drug resistant tuberculosis Horter S et al Plos One 2014;9;e108591 16 8 . 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 17 Lewin S et al. BMJ 2009;339:b3496 18 9 19 Campbell et al BMJ 2000:321:694-696 19 20 20 10 21 Discipline Research method Area of inquiry Antropology Ethnography Holistic meaning of a culture, a cultures shared rules, semantic rules Sociology Grounded theory Social structural processes in a social setting Social interactions Psychology/ Phenomenology Experiences of individuals Philiosophy lifeworld 22 11 . Stemming from a . Flexible and theoretical or independent epistemeological position of theory . Grounded theory . Ethnography . Content analys . Phenomenology . Thematic analysis 23 • 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, Elo S, Kyngäs H. J Adv Nurs. 2008 Apr;62(1):107-15 24 12 25 26 13 27 28 14 29 (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 30 15 . 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. 31 . 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 32 16 . 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 33 34 17 35 • Roots in philosophy- Husserl, early 20th century • Many schools • Lived experience of a phenomenon • Four steps • “Bracketing” • Narrative reading • Coding • Define essens of the phenomena 36 18 …asks for the very nature of a phenomenon, for that which makes a some”thing” what it is and without it could not be what it is 37 38 19 39 39 40 20 . 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 41 . 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 42 21 . Interview . Observation . Document analysis . medical charts, patient diaries 43 . 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. 44 22 Level of control Semistructured open interview with six to eight questions/areas Structured, standardised with Unstructured narrative exact, predetermined questions interview with little interference asked in the same order by the interviewer Structured seminstructured unstructured Polit D & Beck C. Nursing Research. 2012 45 . 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… 46 23 . 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 47 . Individual interview . Focusgroups . Telephone interviews . Repeted interviews 48 24 • Information to the participant • Possible scenario • Pilot interview • Place for interview • Tape recording • Gain trust • Be involved, but keep distance • Debriefing 49 • 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