Ontology and Paradigm What Is Qualitative Method When to Use It

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Anna Strömberg, RN, PhD, FAAN, Professor Department of Medical and Health Sciences, Linköping university Department of Cardiology, Linköping university hospital

. 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

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. 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

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

• 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

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

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

4 Theory Deductive

Inductive Empirics – ”the reality”

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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

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

• Research areas: • Lived experiences, perceptions, thoughts, expectations, motives and attitudes

. 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

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

. 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

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

Lewin S et al. BMJ 2009;339:b3496

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Campbell et al BMJ 2000:321:694-696

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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

11 . Stemming from a . Flexible and theoretical or independent epistemeological position of theory

. Grounded theory . Ethnography . Content analys . Phenomenology . 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, Elo S, Kyngäs H. J Adv Nurs. 2008 Apr;62(1):107-15

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(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

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.

. 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

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

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• 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

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

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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

. 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

21 . 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.

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…

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

. Individual interview . Focusgroups . Telephone interviews . Repeted interviews

24 • 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...

25 . 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

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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 data .Find patterns .Label themes .Develop category systems

.Matrix analysis .Interpreting findings

28 . Meningful units . Codes . Essence . Theory . Themes- subthemes . Category -subcategory

Proprietary Free/open sourse All for Windows*, most macOS All for Windows*, most macOS . NVIVO . RQDA . Atlas . Compendium . QDA Miner* . Aquad . MAXQDA . QDA Miner lite* . Quirkos* . CAT . Dedoose All for text, some for audio, video, social networks, webpages, pictures

29 . Organise and analyse unstructured information . Interviews, pictures, sounds, videos . Transcribe, code, comment, structure the material . Make searches, visualise correlations, analyse . Different user can work jointly . Colour coding . Make graphs, tables, reports

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. 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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32 . 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 . Different types of designs

CONVERGENT DESIGN

Qualitative datacollection and analysis

Compare Interpretation Quantitative datacollection and analysis

EXPLANATORY DESIGN

Quantitative Follow up Qualitative Interpretation datacollection and results datacollection and analysis analysis

EXPLORATORY DESIGN

Qualitative Quantitative datacollection and Develop datacollection and Interpretation analysis analysis

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Lewin S et al. BMJ 2009;339:b3496

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35 . 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

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. Development of instrument . Revision/adaptation of instruments . Translation of instruments

38 . Literature review . questionnaires on patients experiences . Patient interviews  Item generation . Expertpanel – nurses, patients, phycians  Evaluating items adding/deleting/changing items . 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

40 . 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 can 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 Criteria Alternative Criteria for Judging for Judging Quantitative Qualitative Research Research

objectivity mirror 'truth’ confirmability not biased

internal validity methods sound credibility

external validity results applicable transferability in other contexts

reliability consistent and dependability can be repeated

41 . 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

42  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

43 . 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

44 . 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 analysis process. . 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

45 . 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

46 Theoretical framework 9. Methodological orientation and theory What methodological orientation was stated to underpin the study? e.g. grounded theory, phenomenology, content analysis

Participant selection 10. 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?

Setting 14. 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

47 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?