example of qualitative research proposal in health care

Qualitative Research – a practical guide for health and social care researchers and practitioners

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Darshini Ayton, Monash University

Tess Tsindos, Monash University

Danielle Berkovic, Monash University

Copyright Year: 2023

Last Update: 2024

ISBN 13: 9780645755404

Publisher: Monash University

Language: English

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Table of Contents

• Acknowledgement of Country
• About the authors
• Accessibility statement
• Introduction to research
• Research design
• Data collection
• Data analysis
• Writing qualitative research
• Peer review statement
• Licensing and attribution information
• Version history

Ancillary Material

About the book.

This guide is designed to support health and social care researchers and practitioners to integrate qualitative research into the evidence base of health and social care research. Qualitative research designs are diverse and each design has a different focus that will inform the approach undertaken and the results that are generated. The aim is to move beyond the “what” of qualitative research to the “how”, by (1) outlining key qualitative research designs for health and social care research – descriptive, phenomenology, action research, case study, ethnography, and grounded theory; (2) a decision tool of how to select the appropriate design based on a guiding prompting question, the research question and available resources, time and expertise; (3) an overview of mixed methods research and qualitative research in evaluation studies; (4) a practical guide to data collection and analysis; (5) providing examples of qualitative research to illustrate the scope and opportunities; and (6) tips on communicating qualitative research.

About the Contributors

Associate Professor Darshini Ayton is the Deputy Head of the Health and Social Care Unit at Monash University in Melbourne, Australia. She is a transdisciplinary implementation researcher with a focus on improving health and social care for older Australians and operates at the nexus of implementation science, health and social care policies, public health and consumer engagement. She has led qualitative research studies in hospitals, aged care, not-for-profit organisations and for government and utilises a range of data collection methods.  Associate Professor Ayton established and is the director of the highly successful Qualitative Research Methods for Public Health short course which has been running since 2014.

Dr Tess Tsindos  is a Research Fellow with the Health and Social Care Unit at Monash University in Melbourne, Australia. She is a public health researcher and lecturer with strong qualitative and mixed methods research experience conducting research studies in hospital and community health settings, not-for-profit organisations and for government. Prior to working in academia, Dr Tsindos worked in community care for government and not-for-profit organisations for more than 25 years. Dr Tsindos has a strong evaluation background having conducted numerous evaluations for a range of health and social care organisations. Based on this experience she coordinated the Bachelor of Health Science/Public Health Evaluation unit and the Master of Public Health Evaluation unit and developed the Evaluating Public Health Programs short course in 2022. Dr Tsindos is the Unit Coordinator of the Master of Public Health Qualitative Research Methods Unit which was established in 2022.

Dr Danielle Berkovic  is a Research Fellow in the School of Public Health and Preventive Medicine at Monash University in Melbourne, Australia. She is a public health and consumer-led researcher with strong qualitative and mixed-methods research experience focused on improving health services and clinical guidelines for people with arthritis and other musculoskeletal conditions. She has conducted qualitative research studies in hospitals and community health settings. Dr Berkovic currently provides qualitative input into Australia’s first Living Guideline for the pharmacological management of inflammatory arthritis. Dr Berkovic is passionate about incorporating qualitative research methods into traditionally clinical and quantitative spaces and enjoys teaching clinicians and up-and-coming researchers about the benefits of qualitative research.

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Getting started with qualitative research: developing a research proposal, cristina g vivar lecturer, department of community nursing and maternal & child health care, school of nursing, university of navarra, spain, and a doctoral student, nursing studies, school of health in social science, university of edinburgh, uk, anne mcqueen senior lecturer, nursing studies, school of health in social science, university of edinburgh, uk, dorothy a whyte honorary fellow, nursing studies, school of health in social science, university of edinburgh, uk, navidad canga armayor lecturer, head of department of community nursing and maternal & child health care, school of nursing, university of navarra, spain.

The aim of this article is to illustrate in detail important issues that research beginners may have to deal with during the design of a qualitative research proposal in nursing and health care. Cristina Vivar has developed a 17-step process to describe the development of a qualitative research project. This process can serve as an easy way to start research and to ensure a comprehensive and thorough proposal.

Nurse Researcher . 14, 3, 60-73. doi: 10.7748/nr2007.04.14.3.60.c6033

qualitative research - research proposal - research process - proposal design

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Designing a Research Proposal in Qualitative Research

• First Online: 27 October 2022

Cite this chapter

• Md. Ismail Hossain 4 ,
• Nafiul Mehedi 4 &
• Iftakhar Ahmad 4  

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The chapter discusses designing a research proposal in qualitative research. The main objective is to outline the major components of a qualitative research proposal with example(s) so that the students and novice scholars easily get an understanding of a qualitative proposal. The chapter highlights the major components of a qualitative research proposal and discusses the steps involved in designing a proposal. In each step, an example is given with some essential tips. Following these steps and tips, a novice researcher can easily prepare a qualitative research proposal. Readers, especially undergraduate and master’s students, might use this as a guideline while preparing a thesis proposal. After reading this chapter, they can easily prepare a qualitative proposal.

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Designing a qualitative research project.

What is Qualitative in Research

Abdulai, R. T., & Owusu-Ansah, A. (2014). Essential ingredients of a good research proposal for undergraduate and postgraduate students in the social sciences. SAGE Open, 4 (3), 2158244014548178.

Article   Google Scholar  

Ahmad, S., Wasim, S., Irfan, S., Gogoi, S., Srivastava, A., & Farheen, Z. (2019). Qualitative versus quantitative research. Population, 1 , 2.

Google Scholar  

Al-Riyami, A. (2008). How to prepare a research proposal. Oman Medical Journal, 23 (2), 66.

Aspers, P., & Corte, U. (2019). What is qualitative in qualitative research? Qualitative Sociology, 42 (2), 139–160.

Balakumar, P., Inamdar, M. N., & Jagadeesh, G. (2013). The critical steps for successful research: The research proposal and scientific writing (A report on the pre-conference workshop held in conjunction with the 64th annual conference of the Indian Pharmaceutical Congress-2012). Journal of Pharmacology & Pharmacotherapeutics, 4 (2), 130.

Becker, H. (1996). The epistemology of qualitative research. In R. Jessor, A. Colby & R. A Shweder (Eds.), Ethnography and human development: Context and meaning in social inquiry .

Boeije, H. (2010). Analysis in qualitative research . Los Angeles Sage Publications.

Bryman, A., Bresnen, M., Beardsworth, A., & Keil, T. (1988). Qualitative research and the study of leadership. Human Relations, 41 (1), 13–29.

Campbell, D. T., & Stanley, J. C. (2015). Experimental and quasi-experimental designs for research . Ravenio Books.

Creswell, J. W. (1994). Research design: Qualitative and quantitative approach . London: Publications.

Creswell, J. W. (2013). Research design: Qualitative, quantitative, and mixed methods approaches (4th Edn.). London: SAGE Publications, Inc.

Davis, B. (2021). What is the scope of the study in research proposal? Retrieved from https://www.mvorganizing.org/what-is-the-scope-of-the-study-in-research-proposal-4/#What_are_strengths_and_limitations . Accessed on August 28, 2021.

Denzin, N. K., & Lincoln, Y. S. (2005). Introduction: The discipline and practice of qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook of qualitative research (pp. 1–32). Sage Publications Ltd.

DJS Research. (2021). Qualitative research design . Retrieved from https://www.djsresearch.co.uk/glossary/item/Qualitative-Research-Design . Accessed on September 12, 2021.

Durrheim, K. (2006). Research design. In M. T. Blanche, M. J. T. Blanche, K. Durrheim, & D. Painter (Eds.), Research in practice: Applied methods for the social sciences (Vol. 2, pp. 33–59). Juta and Company Ltd.

Editage Insights. (2019). How do I present the scope of my study? Retrieved from https://www.editage.com/insights/how-do-i-present-scope-of-my-study . Accessed on August 31, 2021.

Fry, J., Scammell, J., & Barker, S. (2017). Drowning in muddied waters or swimming downstream? A critical analysis of literature reviewing in a phenomenological study through an exploration of the lifeworld, reflexivity and role of the researcher. Indo-Pacific Journal of Phenomenology , 17 (1).

Grove, S. K., Burns, N., & Gray, J. (2012). The practice of nursing research: Appraisal, synthesis, and generation of evidence . Elsevier Health Sciences.

Islam, M. R. (2019). Designing a Ph.D. proposal in qualitative research. In Social research methodology and new techniques in analysis, interpretation, and writing (pp. 1–22). IGI Global.

James, N., & Busher, H. (2009). Epistemological dimensions in qualitative research: The construction of knowledge online. SAGE Internet Research Methods , 5–18.

Liamputtong, P., & Ezzy, D. (2005). Qualitative research methods. Second . Oxford University Press.

Morse, J. M., & Field, P. A. (1996). The purpose of qualitative research. In Nursing research (pp. 1–17). Springer.

Mouton, J., & Marais, H. C. (1990). Basic concepts in the methodology of the social sciences (Revised). Human Sciences Research Council.

Parahoo, K. (2014). Nursing research: principles, process and issues (3rd ed.). Palgrave.

Pathak, V., Jena, B., & Kalra, S. (2013). Qualitative research. Perspectives in Clinical Research, 4 (3), 192. https://doi.org/10.4103/2229-3485.115389

Patton, A. J. (2001). Modelling time-varying exchange rate dependence using the conditional copula.

Pietilä, A. M., Nurmi, S. M., Halkoaho, A., & Kyngäs, H. (2020). Qualitative research: Ethical considerations. In The application of content analysis in nursing science research (pp. 49–69). Springer.

Rosenthal, M. (2016). Qualitative research methods: Why, when, and how to conduct interviews and focus groups in pharmacy research. Currents in Pharmacy Teaching and Learning, 8 (4), 509–516.

Russell, C. K., & Gregory, D. M. (2003). Evaluation of qualitative research studies. Evidence-Based Nursing, 6 (2), 36–40.

Sandelowski, M., & Barroso, J. (2003). Writing the proposal for a qualitative research methodology project. Qualitative Health Research, 13 (6), 781–820.

Strauss, A., & Corbin, J. (1990). Basics of qualitative research . Sage publications.

Walker, W. (2007). Ethical considerations in phenomenological research. Nurse researcher , 14 (3).

Wilson, A. (2015). A guide to phenomenological research. Nursing Standard, 29 (34), 38–43.

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Hossain, M.I., Mehedi, N., Ahmad, I. (2022). Designing a Research Proposal in Qualitative Research. In: Islam, M.R., Khan, N.A., Baikady, R. (eds) Principles of Social Research Methodology. Springer, Singapore. https://doi.org/10.1007/978-981-19-5441-2_18

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Using qualitative Health Research methods to improve patient and public involvement and engagement in research

• Danielle E. Rolfe 1 ,
• Vivian R. Ramsden 2 ,
• Davina Banner 3 &
• Ian D. Graham 1  

Research Involvement and Engagement volume  4 , Article number:  49 ( 2018 ) Cite this article

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Patient engagement (or patient and public involvement) in health research is becoming a requirement for many health research funders, yet many researchers have little or no experience in engaging patients as partners as opposed to research subjects. Additionally, many patients have no experience providing input on the research design or acting as a decision-making partner on a research team. Several potential risks exist when patient engagement is done poorly, despite best intentions. Some of these risks are that: (1) patients’ involvement is merely tokenism (patients are involved but their suggestions have little influence on how research is conducted); (2) engaged patients do not represent the diversity of people affected by the research; and, (3) research outcomes lack relevance to patients’ lives and experiences.

Qualitative health research (the collection and systematic analysis of non-quantitative data about peoples’ experiences of health or illness and the healthcare system) offers several approaches that can help to mitigate these risks. Several qualitative health research methods, when done well, can help research teams to: (1) accurately incorporate patients’ perspectives and experiences into the design and conduct of research; (2) engage diverse patient perspectives; and, (3) treat patients as equal and ongoing partners on the research team.

This commentary presents several established qualitative health research methods that are relevant to patient engagement in research. The hope is that this paper will inspire readers to seek more information about qualitative health research, and consider how its established methods may help improve the quality and ethical conduct of patient engagement for health research.

Research funders in several countries have posited a new vision for research that involves patients and the public as co-applicants for the funding, and as collaborative partners in decision-making at various stages and/or throughout the research process. Patient engagement (or patient and public involvement) in health research is presented as a more democratic approach that leads to research that is relevant to the lives of the people affected by its outcomes. What is missing from the recent proliferation of resources and publications detailing the practical aspects of patient engagement is a recognition of how existing research methods can inform patient engagement initiatives. Qualitative health research, for example, has established methods of collecting and analyzing non-quantitative data about individuals’ and communities’ lived experiences with health, illness and/or the healthcare system. Included in the paradigm of qualitative health research is participatory health research, which offers approaches to partnering with individuals and communities to design and conduct research that addresses their needs and priorities.

The purpose of this commentary is to explore how qualitative health research methods can inform and support meaningful engagement with patients as partners. Specifically, this paper addresses issues of: rigour (how can patient engagement in research be done well?); representation (are the right patients being engaged?); and, reflexivity (is engagement being done in ways that are meaningful, ethical and equitable?). Various qualitative research methods are presented to increase the rigour found within patient engagement. Approaches to engage more diverse patient perspectives are presented to improve representation beyond the common practice of engaging only one or two patients. Reflexivity, or the practice of identifying and articulating how research processes and outcomes are constructed by the respective personal and professional experiences of researchers and patients, is presented to support the development of authentic, sustainable, equitable and meaningful engagement of patients as partners in health research.

Conclusions

Researchers will need to engage patients as stakeholders in order to satisfy the overlapping mandate in health policy, care and research for engaging patients as partners in decision-making. This paper presents several suggestions to ground patient engagement approaches in established research designs and methods.

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Patient engagement (or patient and public involvement) in research involves partnering with ‘patients’ (a term more often used in Canada and the US, that is inclusive of individuals, caregivers, and/or members of the public) to facilitate research related to health or healthcare services. Rather than research subjects or participants, patients are engaged as partners in the research process. This partnership is intended to be meaningful and ongoing, from the outset of planning a research project, and/or at various stages throughout the research process. Engagement can include the involvement of patients in defining a research question, identifying appropriate outcomes and methods, collecting and interpreting data, and developing and delivering a knowledge translation strategy [ 1 ].

The concept of engaging non-researchers throughout the research process is not new to participatory health researchers, or integrated knowledge translation researchers, as the latter involves ongoing collaboration with clinicians, health planners and policy makers throughout the research process in order to generate new knowledge [ 2 , 3 ]. Patients, however, are less frequently included as partners on health research teams, or as knowledge users in integrated knowledge translation research teams compared to clinicians, healthcare managers and policy-makers, as these individuals are perceived as having “the authority to invoke change in the practice or policy setting.” (p.2) [ 2 ] Recent requirements for patient engagement by health research funders [ 4 , 5 , 6 ], ,and mandates by most healthcare planners and organizations to engage patients in healthcare improvement initiatives, suggest that it would be prudent for integrated knowledge translation (and indeed all) health researchers to begin engaging patients as knowledge users in many, if not all, of their research projects.

Training and tools for patient engagement are being developed and implemented in Canada via the Canadian Institutes for Health Research (CIHR) Strategy for Patient Oriented Research (SPOR) initiative, in the US via Patient Centered Outcomes Research Institute (PCORI), and very practical resources are already available from the UK’s more established INVOLVE Advisory Group [ 5 , 6 , 7 ]. What is seldom provided by these ‘get started’ guides, however, are rigorous methods and evidence-based approaches to engaging diverse patient perspectives, and ensuring that their experiences, values and advice are appropriately incorporated into the research process.

The purpose of this commentary is to stimulate readers’ further discussion and inquiry into qualitative health research methods as a means of fostering the more meaningfully engagement of patients as partners for research. Specifically, this paper will address issues of: rigour (how do we know that the interpretation of patients’ perspectives has been done well and is applicable to other patients?); representation (are multiple and diverse patient perspectives being sought?); and, reflexivity (is engagement being done ethically and equitably?). This commentary alone is insufficient to guide researchers and patient partners to use the methods presented as part of their patient engagement efforts. However, with increased understanding of these approaches and perhaps guidance from experienced qualitative health researchers, integrated knowledge translation and health researchers alike may be better prepared to engage patients in a meaningful way in research that has the potential to improve health and healthcare experiences and outcomes.

What can be learned from methods utilized in qualitative health research?

There is wide variation in researchers’ and healthcare providers’ openness to engaging patients [ 8 ]. Often, the patients that are engaged are a select group of individuals known to the research team, sometimes do not reflect the target population of the research, are involved at a consultative rather than a partnership level, and are more likely to be involved in the planning rather than the dissemination of research [ 9 , 10 , 11 ]. As a result, patient engagement can be seen as tokenistic and the antithesis of the intention of most patient engagement initiatives, which is to have patients’ diverse experiences and perspectives help to shape what and how research is done. The principles, values, and practices of qualitative health research (e.g., relativism, social equity, inductive reasoning) have rich epistemological traditions that align with the conceptual and practical spirit of patient engagement. It is beyond the scope of this commentary, however, to describe in detail the qualitative research paradigm, and readers are encouraged to gain greater knowledge of this topic via relevant courses and texts. Nevertheless, several qualitative research considerations and methods can be applied to the practice of patient engagement, and the following sections describe three of these: rigour, representation and reflexivity.

Rigour: Interpreting and incorporating patients’ experiences into the design and conduct of research

When patient engagement strategies go beyond the inclusion of a few patient partners on the research team, for example, by using focus groups, interviews, community forums, or other methods of seeking input from a broad range of patient perspectives, the diversity of patients’ experiences or perspectives may be a challenge to quickly draw conclusions from in order to make decisions about the study design. To make these decisions, members of the research team (which should include patient partners) may discuss what they heard about patients’ perspectives and suggestions, and then unsystematically incorporate these suggestions, or they may take a vote, try to achieve consensus, implement a Delphi technique [ 12 ], or use another approach designed specifically for patient engagement like the James Lind Alliance technique for priority setting [ 13 ]. Although the information gathered from patients is not data (and indeed would require ethical review to be used as such), a number of qualitative research practices designed to increase rigour can be employed to help ensure that the interpretation and incorporation of patients’ experiences and perspectives has been done systematically and could be reproduced [ 14 ]. These practices include member checking , dense description , and constant comparative analysis . To borrow key descriptors of rigour from qualitative research, these techniques improve “credibility” (i.e., accurate representations of patients’ experiences and preferences that are likely to be understood or recognized by other patients in similar situations – known in quantitative research as internal validity), and “transferability” (or the ability to apply what was found among a group of engaged patients to other patients in similar contexts – known in quantitative research as external validity) [ 15 ].

Member checking

Member checking in qualitative research involves “taking ideas back to the research participants for their confirmation” (p. 111) [ 16 ]. The objective of member checking is to ensure that a researcher’s interpretation of the data (whether a single interview with a participant, or after analyzing several interviews with participants) accurately reflects the participants’ intended meaning (in the case of a member check with a single participant about their interview), or their lived experience (in the case of sharing an overall finding about several individuals with one or more participants) [ 16 ]. For research involving patient engagement, member checking can be utilized to follow-up with patients who may have been engaged at one or only a few time points, or on an on-going basis with patient partners. A summary of what was understood and what decisions were made based on patients’ recommendations could be used to initiate this discussion and followed up with questions such as, “have I understood correctly what you intended to communicate to me?” or “do you see yourself or your experience(s) reflected in these findings or suggestions for the design of the study?”

Dense description

As with quantitative research, detailed information about qualitative research methods and study participants is needed to enable other researchers to understand the context and focus of the research and to establish how these findings relate more broadly. This helps researchers to not only potentially repeat the study, but to extend its findings to similar participants in similar contexts. Dense description provides details of the social, demographic and health profile of participants (e.g., gender, education, health conditions, etc.), as well as the setting and context of their experiences (i.e., where they live, what access to healthcare they have). In this way, dense description improves the transferability of study findings to similar individuals in similar situations [ 15 ]. To date, most studies involving patient engagement provide limited details about their engagement processes and who was engaged [ 17 ]. This omission may be done intentionally (e.g., to protect the privacy of engaged patients, particularly those with stigmatizing health conditions), or as a practical constraint such as publication word limits. Nonetheless, reporting of patient engagement using some aspects of dense description of participants (as appropriate), the ways that they were engaged, and recommendations that emanated from engaged patients can also contribute to greater transferability and understanding of how patient engagement influenced the design of a research study.

Constant comparative analysis

Constant comparative analysis is a method commonly used in grounded theory qualitative research [ 18 ]. Put simply, the understanding of a phenomenon or experience that a researcher acquires through engaging with participants is constantly redeveloped and refined based on subsequent participant interactions. This process of adapting to new information in order to make it more relevant is similar to processes used in rapid cycle evaluation during implementation research [ 19 ]. This method can be usefully adapted and applied to research involving ongoing collaboration and partnership with several engaged patient partners, and/or engagement strategies that seek the perspectives of many patients at various points in the research process. For example, if, in addition to having ongoing patient partners, a larger group of patients provides input and advice (e.g., a steering or advisory committee) at different stages in the research process, their input may result in multiple course corrections during the design and conduct of the research processes to incorporate their suggestions. These suggestions may result in refinement of earlier decisions made about study design or conduct, and as such, the research process becomes more iterative rather than linear. In this way, engaged patients and patient partners are able to provide their input and experience to improve each step of the research process from formulating an appropriate research question or objective, determining best approaches to conducting the research and sharing it with those most affected by the outcomes.

Representation: Gathering diverse perspectives to design relevant and appropriate research studies

The intention of engaging patients is to have their lived experience of health care or a health condition contribute to the optimization of a research project design [ 20 ]. Development of a meaningful and sustainable relationship with patient partners requires considerable time, a demonstrated commitment to partnership by both the patient partners and the researcher(s), resources to facilitate patient partners’ engagement, and often, an individual designated to support the development of this relationship [ 17 , 21 ]. This may lead some research teams to sustain this relationship with only one or two patients who are often previously known to the research team [ 17 ]. The limitation of this approach is that the experiences of these one or two individuals may not adequately reflect the diverse perspectives of patients that may be affected by the research or its outcomes. The notion of gaining ‘ the patient perspective’ from a single or only a few individuals has already been problematized [ 22 , 23 ]. To be sure, the engagement of a single patient is better than none at all, but the engagement of a broader and diverse population of patients should be considered to better inform the research design, and to help prevent further perpetuation of health disparities. Key issues to be considered include (1) how engagement can be made accessible to patients from diverse backgrounds, and (2) which engagement strategies (e.g., ranging from a community information forum to full partnership on the research team) are most appropriate to reach the target population [ 24 ].

Making engagement accessible

Expecting patient partner(s) to attend regular research team meetings held during working hours in a boardroom setting in a hospital, research institute or university limits the participation of many individuals. To support the participation and diversity of engaged patients, effort should be made to increase the accessibility and emotional safety of engagement initiatives [ 25 ]. A budget must be allocated for patient partners’ transportation, childcare or caregiving support, remuneration for time or time taken off work and, at the very least, covering expenses related to their engagement. Another consideration that is often made by qualitative health researchers is whether brief counselling support can be provided to patients should the sharing of their experiences result in emotional distress. There are some resources that can help with planning for costs [ 26 ], including an online cost calculator [ 27 ].

Engagement strategies

Patient partners can be coached to consider the needs and experiences of people unlike them, but there are other methods of engagement that can help to gain a more fulsome perspective of what is likely a diverse patient population that is the focus of the research study. In qualitative health research, this is known as purposeful or purposive sampling: finding people who can provide information-rich descriptions of the phenomenon under study [ 28 ]. Engagement may require different approaches (e.g., deliberative group processes, community forums, focus groups, and patient partners on the research team), at different times in the research process to reach different individuals or populations (e.g., marginalized patients, or patients or caregivers experiencing illnesses that inhibit their ability to maintain an ongoing relationship with the research team). Engagement strategies of different forms at different times may be required. For example, ongoing engagement may occur with patient partners who are members of the research team (e.g., co-applicants on a research grant), and intermittent engagement may be sought from other patients through other methods that may be more time-limited or accessible to a diverse population of patients (e.g., a one-time focus group, community forum, or ongoing online discussion) to address issues that may arise during various stages of the research or dissemination processes. The result of this approach is that patients are not only consulted or involved (one-time or low commitment methods), but are also members of the research team and have the ability to help make decisions about the research being undertaken.

Engagement can generate a wealth of information from very diverse perspectives. Each iteration of engagement may yield new information. Knowing when enough information has been gathered to make decisions with the research team (that includes patient partners) about how the research may be designed or conducted can be challenging. One approach from qualitative research that can be adapted for patient engagement initiatives is theoretical saturation [ 29 ], or “the point in analysis when…further data gathering and analysis add little new to the conceptualization, though variations can always be discovered.” (p. 263) [ 18 ]. That is, a one-time engagement strategy (e.g., a discussion with a single patient partner) may be insufficient to acquire the diverse perspectives of the individuals that will be affected by the research or its outcomes. Additional strategies (e.g., focus groups or interviews with several individuals) may be initiated until many patients identify similar issues or recommendations.

Engagement approaches should also consider: how patients are initially engaged (e.g., through known or new networks, posted notices, telephone or in-person recruitment) and whether involvement has been offered widely enough to garner multiple perspectives; how patients’ experiences are shared (e.g., community forums, formal meetings, individual or group discussions) and whether facilitation enables broad participation; and finally, how patients’ participation and experiences are incorporated into the research planning and design, with patients having equal decision-making capacity to other research team members. Several publications and tools are available that can help guide researchers who are new to processes of engaging patients in research [ 24 , 30 , 31 , 32 , 33 , 34 ], but unfortunately few address how to evaluate the effectiveness of engagement [ 35 ].

Reflexivity: Ensuring meaningful and authentic engagement

In qualitative research, reflexivity is an ongoing process of “the researcher’s scrutiny of his or her research experience, decisions, and interpretations in ways that bring the researcher into the process and allow the reader to assess how and to what extent the researcher’s interests, positions, and assumptions influenced inquiry. A reflexive stance informs how the researcher conducts his or her research, relates to the research participants, and represents them in written reports,” (p.188–189) [ 16 ]. The concept of reflexivity can be applied to research involving patient engagement by continually and explicitly considering how decisions about the research study were made. All members of the research team must consider (and perhaps discuss): (1) how patient partners are invited to participate in research planning and decision-making; (2) how their input is received relative to other team members (i.e., do their suggestions garner the same respect as researchers’ or providers’?); and, (3) whether engaged patients or patient partners feel sufficiently safe, able and respected to share their experiences, preferences and recommendations with the research team.

Ideally, reflexivity becomes a practice within the research team and may be operationalized through regular check-ins with patients and researchers about their comfort in sharing their views, and whether they feel that their views have been considered and taken onboard. Power dynamics should also be considered during patient engagement initiatives. For example, reflecting on how community forums, focus groups or interviews are to be facilitated, including a consideration of who is at the table/who is not, who speaks/who does not, whose suggestions are implemented/whose are not? Reflexivity can be practiced through informal discussions, or using methods that may allow more candid responses by engaged patients (e.g., anonymous online survey or feedback forms). At the very least, if these practices were not conducted throughout the research process, the research team (including patient partners) should endeavor to reflect upon team dynamics and consider how these may have contributed to the research design or outcomes. For example, were physicians and researchers seen as experts and patients felt less welcome or able to share their personal experiences? Were patients only engaged by telephone rather than in-person and did this influence their ability to easily engage in decision-making? Reflexive practices may be usefully supplemented by formal evaluation of the process of patient engagement from the perspective of patients and other research team members [ 36 , 37 ], and some tools are available to do this [ 35 ].

A note about language

One way to address the team dynamic between researchers, professional knowledge users (such as clinicians or health policy planners) and patients is to consider the language used to engage with patients in the planning of patient engagement strategies. That is, the term ‘patient engagement’ is a construction of an individual’s identity that exists only within the healthcare setting, and in the context of a patient-provider dynamic. This term does not consider how people make decisions about their health and healthcare within a broader context of their family, community, and culture [ 22 , 38 ]. This may be why research communities in some countries (e.g., the United Kingdom) use the term ‘patient and public involvement’. Additionally, research that involves communities defined by geography, shared experiences, cultural or ethnic identity, as is the case with participatory health research, may refer to ‘community engagement.’ Regardless of the term used, partnerships with patients, the public, or with communities need to be conceived instead as person-to-person interactions between researchers and individuals who are most affected by the research. Discussions with engaged patients should be conducted early on to determine how to best describe their role on the team or during engagement initiatives (e.g., as patient partners, community members, or people with lived experience).

Tokenism is the “difference between…the empty ritual of participation and having the real power needed to affect the outcome,” (p.2) [ 39 ]. Ongoing reflection on the power dynamic between researchers and engaged patients, a central tenet of critical qualitative health research [ 40 , 41 ], can increase the likelihood that engagement involves equitable processes and will result in meaningful engagement experiences by patients rather than tokenism [ 36 , 42 ]. Patient engagement initiatives should strive for “partnership” amongst all team members, and not just reflect a patient-clinician or researcher-subject dynamic [ 43 ]. To develop meaningful, authentic and sustainable relationships with engaged patients, methods used for participatory, action or community-based research (approaches that fall under the paradigm of qualitative inquiry) provide detailed experiential guidance [ 44 ]. For example, a realist review of community-based participatory research projects reported that gaining and maintaining trust with patient or community partners, although time-intensive, is foundational to equitable and sustainable partnerships that benefit communities and individuals [ 45 , 46 ]. Additionally, Chapter Nine of the Canadian Tri-Council Policy Statement on Research involving Humans, which has to date been applied to research involving First Nations, Inuit and, Métis Peoples in Canada [ 47 ], provides useful information and direction that can be applied to working with patient partners on research [ 48 ].

Authentic patient engagement should include their involvement at all stages of the research process [ 49 , 50 ], but this is often not the case [ 10 ]. .Since patient partners are not research subjects or participants, their engagement does not (usually) require ethics approval, and they can be engaged as partners as early as during the submission of grant applications [ 49 ]. This early engagement helps to incorporate patients’ perspectives into the proposed research before the project is wedded to particular objectives, outcomes and methods, and can also serve to allocate needed resources to support patient engagement (including remuneration for patient partners’ time). Training in research for patient partners can also support their meaningful engagement by increasing their ability to fully engage in decision-making with other members of the research team [ 51 , 52 ]. Patient partners may also thrive in co-leading the dissemination of findings to healthcare providers, researchers, patients or communities most affected by the research [ 53 ].

Patient engagement has gained increasing popularity, but many research organizations are still at the early stages of developing approaches and methods, many of which are based on experience rather than evidence. As health researchers and members of the public will increasingly need to partner for research to satisfy the overlapping mandate of patient engagement in health policy, healthcare and research, the qualitative research methods highlighted in this commentary provide some suggestions to foster rigorous, meaningful and sustained engagement initiatives while addressing broader issues of power and representation. By incorporating evidence-based methods of gathering and learning from multiple and diverse patient perspectives, we will hopefully conduct better patient engaged research, live out the democratic ideals of patient engagement, and ultimately contribute to research that is more relevant to the lives of patients; as well as, contribute to the improved delivery of healthcare services. In addition to the references provided in this paper, readers are encouraged to learn more about the meaningful engagement of patients in research from several key texts [ 54 , 55 , 56 ].

Abbreviations

Canadian Institutes for Health Research

Patient Centered Outcomes Research Institute

Strategy for Patient Oriented Research

Canadian Institutes of Health Research. Strategy for Patient-Oriented Research. 2014. http://www.cihr-irsc.gc.ca/e/documents/spor_framework-en.pdf . Accessed 27 Sep 2017.

Google Scholar  

Kothari A, Wathen CN. Integrated knowledge translation: digging deeper, moving forward. J Epidemiol Community Health. 2017;71:619–23. https://doi.org/10.1136/jech-2016-208490 .

Article   PubMed   Google Scholar  

Gagliardi AR, Berta W, Kothari A, Boyko J, Urquhart R. Integrated knowledge translation (IKT) in health care: a scoping review. Implement Sci. 2016;11:38. https://doi.org/10.1186/s13012-016-0399-1 .

Article   PubMed   PubMed Central   Google Scholar  

Canadian Institutes of Health Research. Strategy for Patient-Oriented Research - CIHR. http://www.cihr-irsc.gc.ca/e/41204.html . Accessed 20 Sep 2017.

Patient-Centered Outcomes Research Institute. Patient-Centered Outcomes Research Institute website. https://www.pcori.org/ . Accessed 20 Sep 2017.

National Institute for Health Research. INVOLVE | INVOLVE Supporting public involvement in NHS, public health and social care research. http://www.invo.org.uk/ . Accessed 27 Sep 2017.

Canadian Institutes of Health Research. SPOR SUPPORT Units - CIHR. http://www.cihr-irsc.gc.ca/e/45859.html . Accessed 27 Sep 2017.

Ocloo J, Matthews R. From tokenism to empowerment: progressing patient and public involvement in healthcare improvement. BMJ Qual Saf. 2016;25:626–32.

Hearld KR, Hearld LR, Hall AG. Engaging patients as partners in research: factors associated with awareness, interest, and engagement as research partners. SAGE open Med. 2017;5:2050312116686709. https://doi.org/10.1177/2050312116686709.

Domecq JP, Prutsky G, Elraiyah T, Wang Z, Nabhan M, Shippee N, et al. Patient engagement in research: a systematic review. BMC Health Serv Res. 2014;14:89. https://doi.org/10.1186/1472-6963-14-89 .

Concannon TW, Fuster M, Saunders T, Patel K, Wong JB, Leslie LK, et al. A systematic review of stakeholder engagement in comparative effectiveness and patient-centered outcomes research. J Gen Intern Med. 2014;29:1692–701.

Oostendorp LJM, Durand M-A, Lloyd A, Elwyn G. Measuring organisational readiness for patient engagement (MORE): an international online Delphi consensus study. BMC Health Serv Res. 2015;15:61. https://doi.org/10.1186/s12913-015-0717-3 .

Boddy K, Cowan K, Gibson A, Britten N. Does funded research reflect the priorities of people living with type 1 diabetes? A secondary analysis of research questions. BMJ Open. 2017;7:e016540. https://doi.org/10.1136/bmjopen-2017-016540 .

Mays N, Pope C. Rigour and qualitative research. BMJ Br Med J. 1995;311:109–12.

Article   CAS   Google Scholar  

Krefting L. Rigor in qualitative research: the assessment of trustworthiness. Am J Occup Ther. 1991;45:214–22.

Article   CAS   PubMed   Google Scholar  

Charmaz K. Constructing grounded theory : a practical guide through qualitative analysis. London: Sage Publications; 2006.

Wilson P, Mathie E, Keenan J, McNeilly E, Goodman C, Howe A, et al. ReseArch with patient and public invOlvement: a RealisT evaluation – the RAPPORT study. Heal Serv Deliv Res. 2015;3:1–176. https://doi.org/10.3310/hsdr03380 .

Corbin JM, Strauss AL, Strauss AL. Basics of qualitative research : techniques and procedures for developing grounded theory. Thousand Oaks: Sage Publications; 2008.

Keith RE, Crosson JC, O’Malley AS, Cromp D, Taylor EF. Using the consolidated framework for implementation research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation. Implement Sci. 2017;12:15. https://doi.org/10.1186/s13012-017-0550-7 .

Esmail L, Moore E. Evaluating patient and stakeholder engagement in research: moving from theory to practice. J Comp Eff Res. 2015;4:133–45. https://doi.org/10.2217/cer.14.79 .

Brett J, Staniszewska S, Mockford C, Herron-Marx S, Hughes J, Tysall C, et al. A systematic review of the impact of patient and public involvement on service users, researchers and communities. Patient. 2014;7:387–95.

Rowland P, McMillan S, McGillicuddy P, Richards J. What is “the patient perspective” in patient engagement programs? Implicit logics and parallels to feminist theories. Heal An Interdiscip J Soc Study Heal Illn Med. 2016. https://doi.org/10.1177/1363459316644494 .

Article   Google Scholar  

Martin GP. “Ordinary people only”: knowledge, representativeness, and the publics of public participation in healthcare. Sociol Health Illn. 2008;30:35–54. https://doi.org/10.1111/j.1467-9566.2007.01027.x .

Snow B, Tweedie K, Pederson A, Shrestha H, Bachmann L. Patient Engagement: Heard and valued. 2013. http://www.cfhi-fcass.ca/sf-docs/default-source/patient-engagement/awesome_workbook-fraserhealth.pdf . Accessed 24 Jan 2018.

Montesanti SR, Abelson J, Lavis JN, Dunn JR. Enabling the participation of marginalized populations: case studies from a health service organization in Ontario. Canada Health Promot Int. 2017;32(4):636–49. https://doi.org/10.1093/heapro/dav118.

The Change Foundation. Should Money Come into It? A Tool for Deciding Whether to Pay Patient- Engagement Participants. Toronto; 2015. http://www.changefoundation.ca/site/wp-content/uploads/2016/05/Should-money-come-into-it.pdf . Accessed 18 June 2018

INVOLVE. Involvement Cost Calculator | INVOLVE. http://www.invo.org.uk/resource-centre/payment-and-recognition-for-public-involvement/involvement-cost-calculator/ . Accessed 11 Oct 2017.

Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks: Sage Publications; 2002.

Kerr C, Nixon A, Wild D. Assessing and demonstrating data saturation in qualitative inquiry supporting patient-reported outcomes research. Expert Rev Pharmacoecon Outcomes Res. 2010;10(3):269–81. https://doi.org/10.1586/erp.10.30 .

Canadian Institutes of Health Research. CIHR’S Citizen Engagement Handbook. http://www.cihr-irsc.gc.ca/e/documents/ce_handbook_e.pdf . Accessed 18 June 2018.

Elliott J, Heesterbeek S, Lukensmeyer CJ, Slocum N. Participatory and deliberative methods toolkit how to connect with citizens: a practitioner’s manual. King Baudouin Foundation; 2005. https://www.kbs-frb.be/en/Virtual-Library/2006/294864 . Accessed 28 Sep 2017.

Robbins M, Tufte J, Hsu C. Learning to “swim” with the experts: experiences of two patient co-investigators for a project funded by the Patient-Centered Outcomes Research Institute. Perm J. 2016;20:85–8.

PubMed   PubMed Central   Google Scholar  

Gauvin F-P, Abelson J, Lavis JN. Strengthening public and patient engagement in health technology assessment in Ontario. 2014. https://www.mcmasterforum.org/docs/default-source/product-documents/evidence-briefs/public-engagement-in-health-technology-assessement-in-ontario-eb.pdf?sfvrsn=2 . Accessed 18 June 2018.

Abelson J, Montesanti S, Li K, Gauvin F-P, Martin E. Effective strategies for interactive public engagement in the development of healthcare policies and Programs. 2010; https://www.cfhi-fcass.ca/sf-docs/default-source/commissionedresearch-reports/Abelson_EN_FINAL.pdf?sfvrsn=0. . Accessed 16 Nov 2018.

Abelson J. Public and patient engagement evaluation tool (version 1.0), vol. 0; 2015. https://www.fhs.mcmaster.ca/publicandpatientengagement/ppeet_request_form.html ! Accessed 18 June 2018

Johnson DS, Bush MT, Brandzel S, Wernli KJ. The patient voice in research—evolution of a role. Res Involv Engagem. 2016;2:6. https://doi.org/10.1186/s40900-016-0020-4 .

Crocker JC, Boylan AM, Bostock J, Locock L. Is it worth it? Patient and public views on the impact of their involvement in health research and its assessment: a UK-based qualitative interview study. Health Expect. 2017;20(3):519–28. https://doi.org/10.1111/hex.12479 .

Renedo A, Marston C. Healthcare professionals’ representations of “patient and public involvement” and creation of “public participant” identities: implications for the development of inclusive and bottom-up community participation initiatives. J Community Appl Soc Psychol. 2011;21:268–80. https://doi.org/10.1002/casp.1092 .

Hahn DL, Hoffmann AE, Felzien M, LeMaster JW, Xu J, Fagnan LJ. Tokenism in patient engagement. Fam Pract. 2017;34(3):290–5. https://doi.org/10.1093/fampra/cmw097.

Hart C, Poole JM, Facey ME, Parsons JA. Holding firm: power, push-Back, and opportunities in navigating the liminal space of critical qualitative Health Research. Qual Health Res. 2017;27:1765–74. https://doi.org/10.1177/1049732317715631 .

Eakin JM. Educating critical qualitative health researchers in the land of the randomized controlled trial. Qual Inq. 2016;22:107–18. https://doi.org/10.1177/1077800415617207 .

Safo S, Cunningham C, Beckman A, Haughton L, Starrels JL. “A place at the table:” a qualitative analysis of community board members’ experiences with academic HIV/AIDS research. BMC Med Res Methodol. 2016;16:80. https://doi.org/10.1186/s12874-016-0181-8 .

Thompson J, Bissell P, Cooper C, Armitage CJ, Barber R, Walker S, et al. Credibility and the “professionalized” lay expert: reflections on the dilemmas and opportunities of public involvement in health research. Heal Interdiscip J Soc Study Heal Illn Med. 2012;16:602–18. https://doi.org/10.1177/1363459312441008 .

Burke JG, Jones J, Yonas M, Guizzetti L, Virata MC, Costlow M, et al. PCOR, CER, and CBPR: alphabet soup or complementary fields of Health Research? Clin Transl Sci. 2013;6:493–6. https://doi.org/10.1111/cts.12064 .

Jagosh J, Bush PL, Salsberg J, Macaulay AC, Greenhalgh T, Wong G, et al. A realist evaluation of community-based participatory research: partnership synergy, trust building and related ripple effects. BMC Public Health. 2015;15:725. https://doi.org/10.1186/s12889-015-1949-1 .

Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, et al. Uncovering the benefits of participatory research: implications of a realist review for health research and practice. Milbank Q. 2012;90:311–46. https://doi.org/10.1111/j.1468-0009.2012.00665.x .

Government of Canada IAP on RE. TCPS 2 - Chapter 9 Research Involving the First Nations, Inuit and Métis Peoples of Canada. http://www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/chapter9-chapitre9/ . Accessed 16 Oct 2017.

Ramsden VR, Crowe J, Rabbitskin N, Rolfe D, Macaulay A. Authentic engagement, co-creation and action research. In: Goodyear-smith F, Mash B, editors. How to do primary care research. Boca Raton: CRC press, medicine, Taylor & Francis Group; 2019.

Ramsden VR, Salsberg J, Herbert CP, Westfall JM, LeMaster J, Macaulay AC. Patient- and community-oriented research: how is authentic engagement identified in grant applications? Can Fam Physician. 2017;63:74–6.

Woolf SH, Zimmerman E, Haley A, Krist AH. Authentic engagement of patients and communities can transform research, practice, and policy. Health Aff. 2016;35:590–4.

Parkes JH, Pyer M, Wray P, Taylor J. Partners in projects: preparing for public involvement in health and social care research. Health Policy. 2014;117:399–408. https://doi.org/10.1016/j.healthpol.2014.04.014 .

Norman N, Bennett C, Cowart S, Felzien M, Flores M, Flores R, et al. Boot camp translation: a method for building a community of solution. J Am Board Fam Med. 2013;26:254–63. https://doi.org/10.3122/jabfm.2013.03.120253 .

Ramsden VR, Rabbitskin N, Westfall JM, Felzien M, Braden J, Sand J. Is knowledge translation without patient or community engagement flawed. Fam Pract. 2016:1–3.

Denzin NK, Lincoln YS. SAGE Handbook of qualitative research. 3rd ed. Thousand Oaks: Sage Publications; 2005.

Pearce V, Baraitser P, Smith G, Greenhalgh T. Experience-based co-design. In: User involvement in health care. Oxford: Wiley-Blackwell; 2010. p. 28–51. https://doi.org/10.1002/9781444325164.ch3 .

Chapter   Google Scholar  

Hulatt I, Lowes L. Involving service users in health and social care research: Routledge; 2005. https://doi.org/10.4324/9780203865651.

Book   Google Scholar  

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Acknowledgements

This paper was drafted in response to a call for concept papers related to integrated knowledge translation issued by the Integrated Knowledge Translation Research Network (CIHR FDN #143237).

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Rolfe, D.E., Ramsden, V.R., Banner, D. et al. Using qualitative Health Research methods to improve patient and public involvement and engagement in research. Res Involv Engagem 4 , 49 (2018). https://doi.org/10.1186/s40900-018-0129-8

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Challenges in conducting qualitative research in health: A conceptual paper

Hamidreza khankeh.

1 Department of Health in Disaster and Emergencies and Nursing, University of Social Welfare and Rehabilitation, Tehran, Iran and Department of Clinical Sciences and Education, Karolinska Institute, Stockholm, Sweden

Maryam Ranjbar

2 Department of Psychology in Institute of Humanities and Social Studies, and Social Determinants of Health Research Center in University of Social Welfare and Rehabilitation, Tehran, Iran

Davoud Khorasani-Zavareh

3 Social Determinants of Health Research Center, Uremia University of Medical Sciences, Uremia, Iran and Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

Ali Zargham-Boroujeni

4 Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Eva Johansson

5 Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden

Background:

Qualitative research focuses on social world and provides the tools to study health phenomena from the perspective of those experiencing them. Identifying the problem, forming the question, and selecting an appropriate methodology and design are some of the initial challenges that researchers encounter in the early stages of any research project. These problems are particularly common for novices.

Materials and Methods:

This article describes the practical challenges of using qualitative inquiry in the field of health and the challenges of performing an interpretive research based on professional experience as a qualitative researcher and on available literature.

One of the main topics discussed is the nature of qualitative research, its inherent challenges, and how to overcome them. Some of those highlighted here include: identification of the research problem, formation of the research question/aim, and selecting an appropriate methodology and research design, which are the main concerns of qualitative researchers and need to be handled properly. Insights from real-life experiences in conducting qualitative research in health reveal these issues.

Conclusions:

The paper provides personal comments on the experiences of a researcher in conducting pure qualitative research in the field of health. It offers insights into the practical difficulties encountered when performing qualitative studies and offers solutions and alternatives applied by these authors, which may be of use to others.

I NTRODUCTION

Health services and health policy research can be based on qualitative research methods, especially when they deal with a rapid change and develop a more fully integrated theory base and research agenda. However, the field must be with the best traditions and techniques of qualitative methods and should distinguish the essentiality of special training and experience in applying these methods.[ 1 ]

Qualitative research methodologies could help improve our understanding of health-related phenomena. Health knowledge must also include interpretive action to maintain scientific quality when research methods are applied. Qualitative and quantitative strategies should be seen as complementary rather than being thought of as incompatible. Although the procedures of interpreting texts are different from those of statistical analysis, due to their different type of data and questions to be answered, the underlying scientific principles are very much the same.[ 2 ]

While working for more than a decade as qualitative designer, Khankeh faced a lot of challenges in conducting qualitative research in the field of health which occupied the mind of other health researchers. Therefore, this article contributes to the discussion of challenges related to qualitative research in healthcare in the light of personal experiences of a researcher conducting purely qualitative health research.

A M AIN I SSUE FOR THE Q UALITATIVE R ESEARCHER

Qualitative research methods involve systematic collection, organizing, and interpretation of material in textual form derived from talk or observations. They are useful to explore the meanings of social phenomena as experienced by individuals in their natural context. The health community still looks at qualitative research with skepticism and accuses it for the subjective nature and absence of facts. Scientific standards, criteria and checklists do exist and the adequacy of guidelines has been vigorously debated within this cross-disciplinary field.[ 2 ]

Clinical knowledge consists of interpretive action and interaction – factors that involve communication, shared opinions, and experiences. The current quantitative research methods indicate a confined access to clinical knowledge, since they insert only the questions and phenomena that can be controlled, measured, and are countable where it is necessary to investigate, share and contest the tacit knowledge of an experienced practitioner. Qualitative research focuses on the people's social world, and not their disease. It is concerned with increased understanding of the meaning of certain conditions for health professionals and patients, and how their relationships are built in a particular social context.[ 3 ] These kinds of research allow exploration of the social events as experienced by individuals in their natural context. Qualitative inquiry could contribute to a broader understanding of health science [ 4 ] considering the substantial congruence between the core elements of health practice and the principles underpinning qualitative research. The globalization progress augments the necessity of qualitative research.[ 5 ]

Corbin (2008) reported that in the past 10 years, the interest in qualitative methods in general and grounded theory in particular has burgeoned according to a review of the literature and dissertation abstracts.[ 6 ]

A researcher engaged in qualitative research will be confronted with a number of challenges. Identifying the research problem and forming the research question are some of the initial challenges that researchers encounter in the early stages of a qualitative research project. Researchers and students sometimes fail to understand that adopting a qualitative approach is only the first stage in the process of selecting an appropriate research methodology.[ 7 ]

Once the initial research question has been identified, the crucial decision to be made is on the selection of an appropriate method, such as content analysis, ethnography, or grounded theory, and selecting the research design as well. Subsequent arrangements would be on the proper methods of data collection, participants, and the research setting, according to the methodology and the research question.[ 8 ] Qualitative researchers should also handle other important concerns such as data analysis, ethical issues, and rigor methods of results.

In this paper, we are going to discuss important practical challenges of qualitative inquiry in health and the challenges faced by researchers using interpretive research methodologies.

U NDERSTANDING THE R EAL N ATURE OF Q UALITATIVE R ESEARCH AND ITS C HALLENGES

It is important to provide an honest and concise appreciation of the essential characteristics of the qualitative research before discussing the challenges of the interpretive research approach to studies in health.

Virtues of qualitative research

Qualitative research does not promise a clear or direct and orderly method of tackling research problems in health studies. It does not provide researchers with a set of rules to be followed or give them a comforting sense of security and safety backup against possible mistakes on the road to knowledge. This research method depends on the “power of words and images,” but does not offer the assimilated meanings such as numbers and equations; it is rather “an attentive search of meaning and understanding” and an attempt for profound comprehension and awareness of the problems and phenomena. The essentially “diagnostic and exploratory nature” of qualitative research is invaluable in developing conceptualizations in health as an evolving discipline. It tenders the possible tap into the sea of complex interactions in health that can be as follows.

Researchers launch the quest for new theories in health which should acknowledge that “qualitative research is an approach rather than a particular set of techniques, and its appropriateness derives from the nature of the social phenomena to be explored.”[ 9 ] In qualitative research, knowledge derives from the context-specific perspective on the experienced phenomena, interpretations, and explanation of social experiences.

Why qualitative research in the health professions?

Researcher should justify the reason for which he or she selected qualitative research. Qualitative researchers pursue a holistic and exclusive perspective. The approach is helpful in understanding human experiences, which is important for health professionals who focus on caring, communication, and interaction.[ 10 ] Many potential researchers intend to find the answer to the questions about a problem or a major issue in clinical practice or quantitative research can not verify them.

In fact, they choose qualitative research for some significant reasons:

• The emotions, perceptions, and actions of people who suffer from a medical condition can be understood by qualitative research
• The meanings of health professions will only be uncovered through observing the interactions of professionals with clients and interviewing about their experience. This is also applicable to the students destined for the healthcare field
• Qualitative research is individualized; hence, researchers consider the participants as whole human beings, not as a bunch of physical compartments
• Observation and asking people are the only ways to understand the causes of particular behaviors. Therefore, this type of research can develop health or education policies; policies for altering health behavior can only be effective if the behavior's basis is clearly understood.[ 10 , 11 ]

Before adhering to a distinct research methodology, researchers have to exactly understand the nature and character of their inquiries and the knowledge they choose to create. The majority of health researchers face many loopholes in justification. However, all defects and challenges of qualitative research should be realized rather than discarded as a compelling way to knowledge structure. New endeavors in excellent academic achievement and building new tradition of qualitative research in health can be facilitated through acknowledging traps and clarifying the real practical challenges.[ 9 ]

Finally, qualitative research provides investigators with the tools to study the health phenomena from the perspective of those experiencing them. This approach is especially applied in situ ations that have not been previously studied, where major gaps exists in research field, and when there is a need for a new perspective to be identified for the arena of health care intervention.[ 6 ]

Based on corbin and strauss (2008), “ Committed qualitative researchers lean toward qualitative work because they are drawn to the fluid, evolving, and dynamic nature of this approach in contrast to the more rigid and structured format of quantitative methods. Qualitative researchers enjoy serendipity and discovery. It is the endless possibilities to learn more about people that qualitative researchers resonate to. It is not distance that qualitative researchers want between themselves and their participants, but the opportunity to connect with them at a human level (Epistemology). Qualitative researchers have a natural curiosity that leads them to study worlds that interest them and that they otherwise might not have access to. Furthermore, qualitative researchers enjoy playing with words, making order out of seeming disorder, and thinking in terms of complex relationships. For them, doing qualitative research is a challenge that brings the whole self into the process .”

Choosing an approach for health research

Researchers select approaches and methodology based on some scientific logics, not on being easy or interesting. The nature and type of the research question or problem; the researcher's epistemological stance, capabilities, knowledge, skills, and training; and the resources available for the research project are the criteria upon which adopting methodology and procedures depend.[ 6 , 10 ]

Inconsistency between research question and methodology, insufficient methodological knowledge, and lack of attention on philosophical underpinning of qualitative methodology can be mentioned as some important challenges here.

There are several different ways of qualitative research and researchers will have to select between various approaches. The qualitative research is based on the theoretical and philosophical assumptions that researchers try to understand. Then, the research methodology and process should be chosen to be consistent with these basic assumptions and the research question as well.[ 10 ]

Some researchers believe that there is no need to study the methodology and methods before beginning the research. Many researchers neglect to gain this knowledge because they are not aware of the qualitative inquiry complexities which make them go wrong. For instance, lack of information about interview, qualitative data analysis, or sampling is very common.[ 10 ]

My experience shows that lack of knowledge, experience, and skills in a research team to do qualitative research can hinder the formation of original knowledge and improvement in understanding the phenomenon under study. The result of such a study will not be new and interesting, and even the study process will be very mechanical without good interpretation or enough exploration. Sometimes there is an inconsistency between research question, research methodology, and basic philosophical assumptions, and the researchers fail to justify their methods of choice in line with the research question and the ontological and epidemiological assumptions.

Finally, the researcher's intentions, the aims of the research question/inquiry, and the chosen approach are regarded as the most important reasons to select a qualitative research method consistent with them and their underpinning philosophical assumptions as well.[ 6 , 10 ]

Research question and aim

Qualitative research is exciting because it asks questions about people's everyday lives and experiences. A qualitative researcher will have the chance of discovering the “significant truths” in the lives of people. That is a wonderful privilege, but you need to get those questions right if you dig into people's lives and ask about their real experiences. An adequate and explicit research question, or a set of interrelated questions, builds the basis for a good research. But excellent research questions are not easy to write at all. A good research requires a good research question as well because it allows us to identify what we really want to know. However, at the beginning of a project, researchers may be uncertain about what exactly they intend to know, so vague questions can lead to an unfocused project.

Common problems coming up with a research question include:

• Deciding about the research area among a range of issues that are heeded in your field of interest
• Not capable of pointing toward any interesting area or topic sufficient to focus a major piece of work on
• Knowing about the area you want to concentrate on (e.g. emergency), but not a certain topic
• Knowing what area and topic is specifically difficult to articulate a clear question.

Just make sure that you give serious consideration to the chosen area as the basis of your research and that a qualitative project is relevant and possible

Having identified a research area, your next step will be to identify a topic within that interesting area. Research questions should be derived from the literature. The research question can come from the list of “suggestions for future work” at the end of a paper you have found interesting. Moreover, you can search for some verifiable gaps through literature review, or based on your personal or professional experience and expert opinion , which should be studied. Therefore, all the previous studies that have already been conducted in the area are considered as important. In this way, you do not run the risk of asking a research question that has already been addressed and/or answered. Based on my experience, novice researchers have some problems finding the right topics in their field of interest because they do not perform a broad literature review to find the gaps and problems suitable to be investigated. Sometimes their field of interest is different from that of their supervisors or there are no experts to help them in this regard.

Although the topic may retain your interest and you may be committed to undertake such a study, it is important to recognize that some topics of personal relevance may also be deeply significant and difficult to research. Finally you need to make sure that your topic of interest is the one that you can actually study within the project constraints such as time and fund.[ 12 ]

Once you have identified your interesting topic for research (according to a broad literature review, personal and professional experience, and/or expert opinion), you can begin to create a research question.

Forming the research question is one of the initial challenges that researchers encounter in the early stages of a research project. Therefore, it acquires significance by the very fact that it provides brief, but nevertheless, important information on the research topic that allows the reader to decide if the topic is relevant, researchable, and a remarkable issue. Furthermore, the research question in qualitative studies has an additional significance as it determines the manner of conducting the study.

The qualitative research question delineates the procedures that are executed in the study and provides a map to the readers by which they can trail the researcher's intentions and actions in the study. Therefore, special attention is needed on how a qualitative research question will specifically be structured, organized, and formed in the way to quote the necessary information and elements that allow the readers to assess and evaluate the study.

The formation of a qualitative research question acquires a basic conducting role for the study and a fundamental function to develop an audit trail that can empower the readers to judge the value, rigor, and validity of the whole research project. Hence, researchers should not only pay special attention toward developing a significant and relevant question, but also formulate it properly. The qualitative research question must be provided in such a way as to impart, reflect, and conjoin the theoretical and abstract assumptions with the practical and pragmatic means of attaining them.

In plain words, a good qualitative research question implicates particular phrasing, whereas the order of words should make the topic of interest amenable to the qualitative quest.

The researcher has to concentrate on how the content of the research topic is understood when phrasing the qualitative research questions, adhering to the topic with the philosophical/theoretical suggestions and to the structure of the study which requires compounding specific principal elements.

The content of a good qualitative research question takes the form of a declarative rather than an interrogative statement

Also, the content provides a brief focus on the issue to be investigated, but does not define the exact relationship of the variables to make these relationships flexible in emanating from the study according to the qualitative research theory. The qualitative research question incepts necessarily with an active verb like understanding, exploring, interpreting, constructing, explaining, describing, etc., to reflect the paradigm/philosophy underpinning the qualitative study. Consequently, specific nouns that represent the aims of qualitative studies, such as experiences, feelings, views, perspectives, knowledge, etc., should be applied. Finally, the methodology or method should appear in the qualitative research question coherent with them. Meanwhile, the structure of a good qualitative research question will address five of the following six: who, when, where, what, how, and why, and the entire research question should devise the sixth element.[ 13 ]

For instance, “Exploring the experiences of self-immolated women regarding their motives for attempting suicide: A qualitative content analysis study in Kermanshah Iran”

Make sure that your research question is consistent with the approach you are adopting. It is like an easy trap if you decide about the research question before considering the proper way by which you are intending to make assumptions and analyze your data.

My experiences show that novice researchers formulate their research question without considering the approach of their study in a proper way and usually their research questions are very broad, unclear, and vague. Since the intention of their studies is not completely clear at the beginning, they cannot decide about the research approach; also, they have to change their research question and take different directions in the course of study or they will end up without adequate results that can help readers or consumers improve their understanding or solve the problem.

Although a researcher initiates a study with a general question and topic, the interesting aspect of qualitative research is that the questions, which are more specific and can help in further data collection and analysis, arise during the course of the study. Thus, a qualitative research question can be broadly, rather than narrowly, focused in the beginning. Researcher can try to refine and make it more focused later. This is why qualitative research is usually cyclic rather than linear. Qualitative research is cyclic, which means that the research question in this approach immerses gradually into the topic. It means that when you come to know more and more about your topic, your ideas develop about what to focus, either through reading, thinking about what you have read, or in early stages of data analysis. Finally, it is literature review, general reading, and discussion with an expert supervisor that can help you find the right topic. If the background knowledge is poor at the beginning of the study, broad but clear research question can be reasonable. Research question may become more focused or develop in a different direction according to more reading and/or preliminary data analysis. A clear and focused research question is articulated and used to conduct further analysis and any future literature reviews necessary for the final write-up.

However, it is very important to take time to choose a research question, because it can be a very challenging exercise. Actually, the ultimate success of the project depends on selecting a clear and convenient question. The question should be appropriate for the qualitative research and for the specific approach you choose which must be grounded in research. It must ask precisely what you want to find out and be articulated and clear. Knowing this will help you plan your project.[ 12 ]

Choosing the right methodology and research design

Crucial decisions need to be made about an appropriate methodology, such as ethnography or grounded theory, after identifying the initial research question. The main concern of novice researchers is to find the reason and appropriate design to do the research, and proper methodology to answer the question. Researchers ought to figure out about the planning of qualitative research and how to choose the methodology.

Researchers sometimes fail to understand that in the process of selecting an adequate research methodology, adopting a qualitative approach is only the first stage. Students, and sometimes researchers, choose qualitative research because they think it is easier to use than the other methodologies. But this reasoning is fumble since qualitative research is a complex methodology where data collection and analysis can be mostly challenging. Sometimes lack of planning and inadequate attention paid to the properness of the selected approach considering the purpose of research will be problematic.

For new qualitative researchers, it often seems that the researcher should totally concentrate on the dual process of data collection and data analysis. It is very important to consider thorough planning in all stages of the research process, from developing the question to the final write-up of the findings for publication.[ 6 ]

The research design and methodology must be adequate to address the selected topics and the research question. Researchers have to identify, describe, and justify the methodology they chose, besides the strategies and procedures involved. So, it is pivotal to find the proper method for the research question. It should be noticed that some of the details of a qualitative research project cannot be ascertained in advance and may be specified as they arise during the research process.[ 10 ] An important problem for novice researchers is the little acknowledgement of different approaches that address different kinds and levels of questions and take a different stance on the kind of phenomena which is focused upon. More discussion and debates are necessary before selecting and justifying an approach.

The need for consistency and coherence becomes more obvious when we consider the risk of something called “method-slurring.” This is the problem of blurring distinctions between qualitative approaches. Each approach has to demonstrate its consistency to its foundations and will reflect them in data collection, analysis, and knowledge claim.

It may be important to acknowledge the distinctive features by specific approaches such as phenomenology or grounded theory at some levels such as the type of question they are suited to answer, data collection methods they are consistent with, and also the kinds of analysis and presentation of the results that fit within the approach – such as “goodness of fit” or logical staged linking – and can be referred to as “consistency.”

If such consistency occurs, then the whole thing “hangs together” as coherent; that is, the kind of knowledge generated in the results or presentation section doing what is said it would do following the aims of the project. In order to consider these criteria of consistency and coherence in greater detail, we need to look at the distinctive differences between qualitative approaches in the following: the aims of the research approach, its roots in different disciplines and ideologies, the knowledge claims linked to it, and to a lesser extent, the data collection and analysis specific to each approach.[ 11 ]

My experience shows that novice researchers have some problems to justify their methodology of choice and sometimes they experience some degree of methodological slurring. They do not have any clear understanding of the research process in terms of data gathering strategies, data analysis method, and even appropriate sampling plan, which should be indentified based on philosophical and methodological principles.

Finally, besides the above-mentioned problems, regarding research design, there are two common problems encountered especially by students who want to do qualitative study; sometimes researchers and research team try to identify everything, even the sample size, in advance when they design their study because they have a strong background of quantitative research, and this is completely in contrast with the flexible nature and explorative approach of qualitative research. The other problem is the examination committee and the format of proposal of grant sites and funding agencies, which are based on the principles of quantitative study. This rigid format pushes the researchers to try to clarify everything in advance. So, flexibility is regarded as the most important credibility criterion in all kinds of qualitative research and it should be considered when designing the study and following its process.[ 1 ]

C ONCLUSIONS

Qualitative research focuses on social world and provides investigators with the tools to study health phenomena from the perspective of those experiencing them.

Identifying the research problem, forming the research question, and selecting an appropriate methodology and research design are some of the initial challenges that researchers encounter in the early stages of a qualitative research project.

Once the research problem and the initial research question are identified, the crucial decision has to be made in selecting the appropriate methodology. Subsequent arrangements would be on the proper methods of data collection, and choosing the participants and the research setting according to the methodology and the research question. It is highly recommended that the researchers exactly understand the nature and character of their inquiries and the knowledge they choose to create before adhering to a distinct research methodology based on scientific knowledge.

The essence and type of the research question or problem, the researcher's epistemological stance, capabilities, knowledge, skills and training, and the resources available for the research project are the criteria upon which the adopting methodology and procedures depend.

Inconsistency between research question and methodology, insufficient methodological knowledge, and lack of attention to the philosophical underpinning of qualitative methodology are some important challenges.

Lack of knowledge, experience, and skills to do qualitative research can hinder the formation of original knowledge and improvement in understanding the phenomenon under study. The result of such a study will not be new and interesting, and even the study process will be very mechanical without good interpretation or enough exploration. A good research requires a good research question as well because it allows us to identify what we really want to know. However, at the beginning of a project, researchers may be wavering about what they exactly intend to know; so, vague questions can lead to an unfocused project.

Broad literature review, personal and professional experience, and/or expert opinion can be regarded as the main sources to identify interesting research topics and research questions as well. Forming the research question is one of the initial challenges that researchers encounter in the early stages of a research project. Therefore, it acquires significance by the very fact that it provides brief, but nevertheless, important information on the research topic that allows the reader to decide if the topic is relevant, researchable, and a remarkable issue that can help the researcher to determine the manner of conducting the study.

Then crucial decisions need to be made about an appropriate methodology. The main concern of novice researchers is to find the reason and appropriate design to do the research and the proper methodology to answer the question. Researchers first ought to figure out the planning of qualitative research and how to choose the methodology.

It is very important to consider thorough planning in all stages of the research process, from developing the question to final write-up of the findings for publication. It is worth knowing that some of the details of a qualitative research project cannot be ascertained in advance and may be specified as they arise during the research process. For a novice researcher, more discussions and debates are necessary before selecting and justifying an approach.

Method-slurring is another common problem, which means the act of blurring distinctions between qualitative approaches. Each approach has to demonstrate its consistency to its foundations and will reflect them in data collection, analysis, and knowledge claim.

It is not rare to find that researchers and research team try to identify everything, even sample size, in advance when they design their qualitative study because of the strong background they have about the quantitative research. This is completely in contrast with the flexible nature and explorative approach of qualitative research; as these kinds of researches are completely explorative, the mentioned issues – such as sample size – should be clarified in the course of the study.

The other problem is the examination committee and the format of proposal in the grant sites and funding agencies, which is based on the principles of quantitative study. Therefore, flexibility is actually the most important credibility criterion in all qualitative researches that should be considered when a study is designed and the study process is followed.

As the final word, the researcher should make sure that he/she gives serious consideration to the chosen area as the basis of research and that a qualitative project is relevant and possible. Thus, forming the research question in a proper way and selecting appropriate methodology can guarantee original, interesting, and applied knowledge, which at least can increase our understanding about the meaning of certain conditions for professionals and patients and how their relationships are built in a particular social context.

Source of Support: Nil

Conflict of Interest: None declared.

R EFERENCES

• Correspondence
• Open access
• Published: 09 September 2011

How to do a grounded theory study: a worked example of a study of dental practices

• Alexandra Sbaraini 1 , 2 ,
• Stacy M Carter 1 ,
• R Wendell Evans 2 &
• Anthony Blinkhorn 1 , 2  

BMC Medical Research Methodology volume  11 , Article number:  128 ( 2011 ) Cite this article

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Qualitative methodologies are increasingly popular in medical research. Grounded theory is the methodology most-often cited by authors of qualitative studies in medicine, but it has been suggested that many 'grounded theory' studies are not concordant with the methodology. In this paper we provide a worked example of a grounded theory project. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

We documented a worked example of using grounded theory methodology in practice.

We describe our sampling, data collection, data analysis and interpretation. We explain how these steps were consistent with grounded theory methodology, and show how they related to one another. Grounded theory methodology assisted us to develop a detailed model of the process of adapting preventive protocols into dental practice, and to analyse variation in this process in different dental practices.

Conclusions

By employing grounded theory methodology rigorously, medical researchers can better design and justify their methods, and produce high-quality findings that will be more useful to patients, professionals and the research community.

Peer Review reports

Qualitative research is increasingly popular in health and medicine. In recent decades, qualitative researchers in health and medicine have founded specialist journals, such as Qualitative Health Research , established 1991, and specialist conferences such as the Qualitative Health Research conference of the International Institute for Qualitative Methodology, established 1994, and the Global Congress for Qualitative Health Research, established 2011 [ 1 – 3 ]. Journals such as the British Medical Journal have published series about qualitative methodology (1995 and 2008) [ 4 , 5 ]. Bodies overseeing human research ethics, such as the Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, and the Australian National Statement on Ethical Conduct in Human Research [ 6 , 7 ], have included chapters or sections on the ethics of qualitative research. The increasing popularity of qualitative methodologies for medical research has led to an increasing awareness of formal qualitative methodologies. This is particularly so for grounded theory, one of the most-cited qualitative methodologies in medical research [[ 8 ], p47].

Grounded theory has a chequered history [ 9 ]. Many authors label their work 'grounded theory' but do not follow the basics of the methodology [ 10 , 11 ]. This may be in part because there are few practical examples of grounded theory in use in the literature. To address this problem, we will provide a brief outline of the history and diversity of grounded theory methodology, and a worked example of the methodology in practice. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

The history, diversity and basic components of 'grounded theory' methodology and method

Founded on the seminal 1967 book 'The Discovery of Grounded Theory' [ 12 ], the grounded theory tradition is now diverse and somewhat fractured, existing in four main types, with a fifth emerging. Types one and two are the work of the original authors: Barney Glaser's 'Classic Grounded Theory' [ 13 ] and Anselm Strauss and Juliet Corbin's 'Basics of Qualitative Research' [ 14 ]. Types three and four are Kathy Charmaz's 'Constructivist Grounded Theory' [ 15 ] and Adele Clarke's postmodern Situational Analysis [ 16 ]: Charmaz and Clarke were both students of Anselm Strauss. The fifth, emerging variant is 'Dimensional Analysis' [ 17 ] which is being developed from the work of Leonard Schaztman, who was a colleague of Strauss and Glaser in the 1960s and 1970s.

There has been some discussion in the literature about what characteristics a grounded theory study must have to be legitimately referred to as 'grounded theory' [ 18 ]. The fundamental components of a grounded theory study are set out in Table 1 . These components may appear in different combinations in other qualitative studies; a grounded theory study should have all of these. As noted, there are few examples of 'how to do' grounded theory in the literature [ 18 , 19 ]. Those that do exist have focused on Strauss and Corbin's methods [ 20 – 25 ]. An exception is Charmaz's own description of her study of chronic illness [ 26 ]; we applied this same variant in our study. In the remainder of this paper, we will show how each of the characteristics of grounded theory methodology worked in our study of dental practices.

Study background

We used grounded theory methodology to investigate social processes in private dental practices in New South Wales (NSW), Australia. This grounded theory study builds on a previous Australian Randomized Controlled Trial (RCT) called the Monitor Dental Practice Program (MPP) [ 27 ]. We know that preventive techniques can arrest early tooth decay and thus reduce the need for fillings [ 28 – 32 ]. Unfortunately, most dentists worldwide who encounter early tooth decay continue to drill it out and fill the tooth [ 33 – 37 ]. The MPP tested whether dentists could increase their use of preventive techniques. In the intervention arm, dentists were provided with a set of evidence-based preventive protocols to apply [ 38 ]; control practices provided usual care. The MPP protocols used in the RCT guided dentists to systematically apply preventive techniques to prevent new tooth decay and to arrest early stages of tooth decay in their patients, therefore reducing the need for drilling and filling. The protocols focused on (1) primary prevention of new tooth decay (tooth brushing with high concentration fluoride toothpaste and dietary advice) and (2) intensive secondary prevention through professional treatment to arrest tooth decay progress (application of fluoride varnish, supervised monitoring of dental plaque control and clinical outcomes)[ 38 ].

As the RCT unfolded, it was discovered that practices in the intervention arm were not implementing the preventive protocols uniformly. Why had the outcomes of these systematically implemented protocols been so different? This question was the starting point for our grounded theory study. We aimed to understand how the protocols had been implemented, including the conditions and consequences of variation in the process. We hoped that such understanding would help us to see how the norms of Australian private dental practice as regards to tooth decay could be moved away from drilling and filling and towards evidence-based preventive care.

Designing this grounded theory study

Figure 1 illustrates the steps taken during the project that will be described below from points A to F.

Study design . file containing a figure illustrating the study design.

A. An open beginning and research questions

Grounded theory studies are generally focused on social processes or actions: they ask about what happens and how people interact . This shows the influence of symbolic interactionism, a social psychological approach focused on the meaning of human actions [ 39 ]. Grounded theory studies begin with open questions, and researchers presume that they may know little about the meanings that drive the actions of their participants. Accordingly, we sought to learn from participants how the MPP process worked and how they made sense of it. We wanted to answer a practical social problem: how do dentists persist in drilling and filling early stages of tooth decay, when they could be applying preventive care?

We asked research questions that were open, and focused on social processes. Our initial research questions were:

What was the process of implementing (or not-implementing) the protocols (from the perspective of dentists, practice staff, and patients)?

How did this process vary?

B. Ethics approval and ethical issues

In our experience, medical researchers are often concerned about the ethics oversight process for such a flexible, unpredictable study design. We managed this process as follows. Initial ethics approval was obtained from the Human Research Ethics Committee at the University of Sydney. In our application, we explained grounded theory procedures, in particular the fact that they evolve. In our initial application we provided a long list of possible recruitment strategies and interview questions, as suggested by Charmaz [ 15 ]. We indicated that we would make future applications to modify our protocols. We did this as the study progressed - detailed below. Each time we reminded the committee that our study design was intended to evolve with ongoing modifications. Each modification was approved without difficulty. As in any ethical study, we ensured that participation was voluntary, that participants could withdraw at any time, and that confidentiality was protected. All responses were anonymised before analysis, and we took particular care not to reveal potentially identifying details of places, practices or clinicians.

C. Initial, Purposive Sampling (before theoretical sampling was possible)

Grounded theory studies are characterised by theoretical sampling, but this requires some data to be collected and analysed. Sampling must thus begin purposively, as in any qualitative study. Participants in the previous MPP study provided our population [ 27 ]. The MPP included 22 private dental practices in NSW, randomly allocated to either the intervention or control group. With permission of the ethics committee; we sent letters to the participants in the MPP, inviting them to participate in a further qualitative study. From those who agreed, we used the quantitative data from the MPP to select an initial sample.

Then, we selected the practice in which the most dramatic results had been achieved in the MPP study (Dental Practice 1). This was a purposive sampling strategy, to give us the best possible access to the process of successfully implementing the protocols. We interviewed all consenting staff who had been involved in the MPP (one dentist, five dental assistants). We then recruited 12 patients who had been enrolled in the MPP, based on their clinically measured risk of developing tooth decay: we selected some patients whose risk status had gotten better, some whose risk had worsened and some whose risk had stayed the same. This purposive sample was designed to provide maximum variation in patients' adoption of preventive dental care.

Initial Interviews

One hour in-depth interviews were conducted. The researcher/interviewer (AS) travelled to a rural town in NSW where interviews took place. The initial 18 participants (one dentist, five dental assistants and 12 patients) from Dental Practice 1 were interviewed in places convenient to them such as the dental practice, community centres or the participant's home.

Two initial interview schedules were designed for each group of participants: 1) dentists and dental practice staff and 2) dental patients. Interviews were semi-structured and based loosely on the research questions. The initial questions for dentists and practice staff are in Additional file 1 . Interviews were digitally recorded and professionally transcribed. The research location was remote from the researcher's office, thus data collection was divided into two episodes to allow for intermittent data analysis. Dentist and practice staff interviews were done in one week. The researcher wrote memos throughout this week. The researcher then took a month for data analysis in which coding and memo-writing occurred. Then during a return visit, patient interviews were completed, again with memo-writing during the data-collection period.

D. Data Analysis

Coding and the constant comparative method.

Coding is essential to the development of a grounded theory [ 15 ]. According to Charmaz [[ 15 ], p46], 'coding is the pivotal link between collecting data and developing an emergent theory to explain these data. Through coding, you define what is happening in the data and begin to grapple with what it means'. Coding occurs in stages. In initial coding, the researcher generates as many ideas as possible inductively from early data. In focused coding, the researcher pursues a selected set of central codes throughout the entire dataset and the study. This requires decisions about which initial codes are most prevalent or important, and which contribute most to the analysis. In theoretical coding, the researcher refines the final categories in their theory and relates them to one another. Charmaz's method, like Glaser's method [ 13 ], captures actions or processes by using gerunds as codes (verbs ending in 'ing'); Charmaz also emphasises coding quickly, and keeping the codes as similar to the data as possible.

We developed our coding systems individually and through team meetings and discussions.

We have provided a worked example of coding in Table 2 . Gerunds emphasise actions and processes. Initial coding identifies many different processes. After the first few interviews, we had a large amount of data and many initial codes. This included a group of codes that captured how dentists sought out evidence when they were exposed to a complex clinical case, a new product or technique. Because this process seemed central to their practice, and because it was talked about often, we decided that seeking out evidence should become a focused code. By comparing codes against codes and data against data, we distinguished the category of "seeking out evidence" from other focused codes, such as "gathering and comparing peers' evidence to reach a conclusion", and we understood the relationships between them. Using this constant comparative method (see Table 1 ), we produced a theoretical code: "making sense of evidence and constructing knowledge". This code captured the social process that dentists went through when faced with new information or a practice challenge. This theoretical code will be the focus of a future paper.

Memo-writing

Throughout the study, we wrote extensive case-based memos and conceptual memos. After each interview, the interviewer/researcher (AS) wrote a case-based memo reflecting on what she learned from that interview. They contained the interviewer's impressions about the participants' experiences, and the interviewer's reactions; they were also used to systematically question some of our pre-existing ideas in relation to what had been said in the interview. Table 3 illustrates one of those memos. After a few interviews, the interviewer/researcher also began making and recording comparisons among these memos.

We also wrote conceptual memos about the initial codes and focused codes being developed, as described by Charmaz [ 15 ]. We used these memos to record our thinking about the meaning of codes and to record our thinking about how and when processes occurred, how they changed, and what their consequences were. In these memos, we made comparisons between data, cases and codes in order to find similarities and differences, and raised questions to be answered in continuing interviews. Table 4 illustrates a conceptual memo.

At the end of our data collection and analysis from Dental Practice 1, we had developed a tentative model of the process of implementing the protocols, from the perspective of dentists, dental practice staff and patients. This was expressed in both diagrams and memos, was built around a core set of focused codes, and illustrated relationships between them.

E. Theoretical sampling, ongoing data analysis and alteration of interview route

We have already described our initial purposive sampling. After our initial data collection and analysis, we used theoretical sampling (see Table 1 ) to determine who to sample next and what questions to ask during interviews. We submitted Ethics Modification applications for changes in our question routes, and had no difficulty with approval. We will describe how the interview questions for dentists and dental practice staff evolved, and how we selected new participants to allow development of our substantive theory. The patients' interview schedule and theoretical sampling followed similar procedures.

Evolution of theoretical sampling and interview questions

We now had a detailed provisional model of the successful process implemented in Dental Practice 1. Important core focused codes were identified, including practical/financial, historical and philosophical dimensions of the process. However, we did not yet understand how the process might vary or go wrong, as implementation in the first practice we studied had been described as seamless and beneficial for everyone. Because our aim was to understand the process of implementing the protocols, including the conditions and consequences of variation in the process, we needed to understand how implementation might fail. For this reason, we theoretically sampled participants from Dental Practice 2, where uptake of the MPP protocols had been very limited according to data from the RCT trial.

We also changed our interview questions based on the analysis we had already done (see Additional file 2 ). In our analysis of data from Dental Practice 1, we had learned that "effectiveness" of treatments and "evidence" both had a range of meanings. We also learned that new technologies - in particular digital x-rays and intra-oral cameras - had been unexpectedly important to the process of implementing the protocols. For this reason, we added new questions for the interviews in Dental Practice 2 to directly investigate "effectiveness", "evidence" and how dentists took up new technologies in their practice.

Then, in Dental Practice 2 we learned more about the barriers dentists and practice staff encountered during the process of implementing the MPP protocols. We confirmed and enriched our understanding of dentists' processes for adopting technology and producing knowledge, dealing with complex cases and we further clarified the concept of evidence. However there was a new, important, unexpected finding in Dental Practice 2. Dentists talked about "unreliable" patients - that is, patients who were too unreliable to have preventive dental care offered to them. This seemed to be a potentially important explanation for non-implementation of the protocols. We modified our interview schedule again to include questions about this concept (see Additional file 3 ) leading to another round of ethics approvals. We also returned to Practice 1 to ask participants about the idea of an "unreliable" patient.

Dentists' construction of the "unreliable" patient during interviews also prompted us to theoretically sample for "unreliable" and "reliable" patients in the following round of patients' interviews. The patient question route was also modified by the analysis of the dentists' and practice staff data. We wanted to compare dentists' perspectives with the perspectives of the patients themselves. Dentists were asked to select "reliable" and "unreliable" patients to be interviewed. Patients were asked questions about what kind of services dentists should provide and what patients valued when coming to the dentist. We found that these patients (10 reliable and 7 unreliable) talked in very similar ways about dental care. This finding suggested to us that some deeply-held assumptions within the dental profession may not be shared by dental patients.

At this point, we decided to theoretically sample dental practices from the non-intervention arm of the MPP study. This is an example of the 'openness' of a grounded theory study potentially subtly shifting the focus of the study. Our analysis had shifted our focus: rather than simply studying the process of implementing the evidence-based preventive protocols, we were studying the process of doing prevention in private dental practice. All participants seemed to be revealing deeply held perspectives shared in the dental profession, whether or not they were providing dental care as outlined in the MPP protocols. So, by sampling dentists from both intervention and control group from the previous MPP study, we aimed to confirm or disconfirm the broader reach of our emerging theory and to complete inductive development of key concepts. Theoretical sampling added 12 face to face interviews and 10 telephone interviews to the data. A total of 40 participants between the ages of 18 and 65 were recruited. Telephone interviews were of comparable length, content and quality to face to face interviews, as reported elsewhere in the literature [ 40 ].

F. Mapping concepts, theoretical memo writing and further refining of concepts

After theoretical sampling, we could begin coding theoretically. We fleshed out each major focused code, examining the situations in which they appeared, when they changed and the relationship among them. At time of writing, we have reached theoretical saturation (see Table 1 ). We have been able to determine this in several ways. As we have become increasingly certain about our central focused codes, we have re-examined the data to find all available insights regarding those codes. We have drawn diagrams and written memos. We have looked rigorously for events or accounts not explained by the emerging theory so as to develop it further to explain all of the data. Our theory, which is expressed as a set of concepts that are related to one another in a cohesive way, now accounts adequately for all the data we have collected. We have presented the developing theory to specialist dental audiences and to the participants, and have found that it was accepted by and resonated with these audiences.

We have used these procedures to construct a detailed, multi-faceted model of the process of incorporating prevention into private general dental practice. This model includes relationships among concepts, consequences of the process, and variations in the process. A concrete example of one of our final key concepts is the process of "adapting to" prevention. More commonly in the literature writers speak of adopting, implementing or translating evidence-based preventive protocols into practice. Through our analysis, we concluded that what was required was 'adapting to' those protocols in practice. Some dental practices underwent a slow process of adapting evidence-based guidance to their existing practice logistics. Successful adaptation was contingent upon whether (1) the dentist-in-charge brought the whole dental team together - including other dentists - and got everyone interested and actively participating during preventive activities; (2) whether the physical environment of the practice was re-organised around preventive activities, (3) whether the dental team was able to devise new and efficient routines to accommodate preventive activities, and (4) whether the fee schedule was amended to cover the delivery of preventive services, which hitherto was considered as "unproductive time".

Adaptation occurred over time and involved practical, historical and philosophical aspects of dental care. Participants transitioned from their initial state - selling restorative care - through an intermediary stage - learning by doing and educating patients about the importance of preventive care - and finally to a stage where they were offering patients more than just restorative care. These are examples of ways in which participants did not simply adopt protocols in a simple way, but needed to adapt the protocols and their own routines as they moved toward more preventive practice.

The quality of this grounded theory study

There are a number of important assurances of quality in keeping with grounded theory procedures and general principles of qualitative research. The following points describe what was crucial for this study to achieve quality.

During data collection

1. All interviews were digitally recorded, professionally transcribed in detail and the transcripts checked against the recordings.

2. We analysed the interview transcripts as soon as possible after each round of interviews in each dental practice sampled as shown on Figure 1 . This allowed the process of theoretical sampling to occur.

3. Writing case-based memos right after each interview while being in the field allowed the researcher/interviewer to capture initial ideas and make comparisons between participants' accounts. These memos assisted the researcher to make comparison among her reflections, which enriched data analysis and guided further data collection.

4. Having the opportunity to contact participants after interviews to clarify concepts and to interview some participants more than once contributed to the refinement of theoretical concepts, thus forming part of theoretical sampling.

5. The decision to include phone interviews due to participants' preference worked very well in this study. Phone interviews had similar length and depth compared to the face to face interviews, but allowed for a greater range of participation.

During data analysis

1. Detailed analysis records were kept; which made it possible to write this explanatory paper.

2. The use of the constant comparative method enabled the analysis to produce not just a description but a model, in which more abstract concepts were related and a social process was explained.

3. All researchers supported analysis activities; a regular meeting of the research team was convened to discuss and contextualize emerging interpretations, introducing a wide range of disciplinary perspectives.

Answering our research questions

We developed a detailed model of the process of adapting preventive protocols into dental practice, and analysed the variation in this process in different dental practices. Transferring evidence-based preventive protocols into these dental practices entailed a slow process of adapting the evidence to the existing practices logistics. Important practical, philosophical and historical elements as well as barriers and facilitators were present during a complex adaptation process. Time was needed to allow dentists and practice staff to go through this process of slowly adapting their practices to this new way of working. Patients also needed time to incorporate home care activities and more frequent visits to dentists into their daily routines. Despite being able to adapt or not, all dentists trusted the concrete clinical evidence that they have produced, that is, seeing results in their patients mouths made them believe in a specific treatment approach.

Concluding remarks

This paper provides a detailed explanation of how a study evolved using grounded theory methodology (GTM), one of the most commonly used methodologies in qualitative health and medical research [[ 8 ], p47]. In 2007, Bryant and Charmaz argued:

'Use of GTM, at least as much as any other research method, only develops with experience. Hence the failure of all those attempts to provide clear, mechanistic rules for GTM: there is no 'GTM for dummies'. GTM is based around heuristics and guidelines rather than rules and prescriptions. Moreover, researchers need to be familiar with GTM, in all its major forms, in order to be able to understand how they might adapt it in use or revise it into new forms and variations.' [[ 8 ], p17].

Our detailed explanation of our experience in this grounded theory study is intended to provide, vicariously, the kind of 'experience' that might help other qualitative researchers in medicine and health to apply and benefit from grounded theory methodology in their studies. We hope that our explanation will assist others to avoid using grounded theory as an 'approving bumper sticker' [ 10 ], and instead use it as a resource that can greatly improve the quality and outcome of a qualitative study.

Abbreviations

grounded theory methods

Monitor Dental Practice Program

New South Wales

Randomized Controlled Trial.

Qualitative Health Research Journal: website accessed on 10 June 2011, [ http://qhr.sagepub.com/ ]

Qualitative Health Research conference of The International Institute for Qualitative Methodology: website accessed on 10 June 2011, [ http://www.iiqm.ualberta.ca/en/Conferences/QualitativeHealthResearch.aspx ]

The Global Congress for Qualitative Health Research: website accessed on 10 June 2011, [ http://www.gcqhr.com/ ]

Mays N, Pope C: Qualitative research: observational methods in health care settings. BMJ. 1995, 311: 182-

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kuper A, Reeves S, Levinson W: Qualitative research: an introduction to reading and appraising qualitative research. BMJ. 2008, 337: a288-10.1136/bmj.a288.

Article   PubMed   Google Scholar  

Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, Social Sciences and Humanities Research Council of Canada, Tri-Council Policy Statemen: Ethical Conduct for Research Involving Humans . 1998, website accessed on 13 September 2011, [ http://www.pre.ethics.gc.ca/english/policystatement/introduction.cfm ]

Google Scholar  

The Australian National Statement on Ethical Conduct in Human Research: website accessed on 10 June 2011, [ http://www.nhmrc.gov.au/publications/synopses/e35syn.htm ]

Bryant A, Charmaz K, (eds.): Handbook of Grounded Theory. 2007, London: Sage

Walker D, Myrick F: Grounded theory: an exploration of process and procedure. Qual Health Res. 2006, 16: 547-559. 10.1177/1049732305285972.

Barbour R: Checklists for improving rigour in qualitative research: A case of the tail wagging the dog?. BMJ. 2001, 322: 1115-1117. 10.1136/bmj.322.7294.1115.

Dixon-Woods M, Booth A, Sutton AJ: Synthesizing qualitative research: a review of published reports. Qual Res. 2007, 7 (3): 375-422. 10.1177/1468794107078517.

Article   Google Scholar  

Glaser BG, Strauss AL: The Discovery of Grounded Theory: Strategies for Qualitative Research. 1967, Chicago: Aldine

Glaser BG: Basics of Grounded Theory Analysis. Emergence vs Forcing. 1992, Mill Valley CA, USA: Sociology Press

Corbin J, Strauss AL: Basics of qualitative research. 2008, Thousand Oaks, CA: Sage, 3

Charmaz K: Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. 2006, London: Sage

Clarke AE: Situational Analysis. Grounded Theory after the Postmodern Turn. 2005, Thousand Oaks, CA: Sage

Bowers B, Schatzman L: Dimensional Analysis. Developing Grounded Theory: The Second Generation. Edited by: Morse JM, Stern PN, Corbin J, Bowers B, Charmaz K, Clarke AE. 2009, Walnut Creek, CA, USA: Left Coast Press, 86-125.

Morse JM, Stern PN, Corbin J, Bowers B, Charmaz K, Clarke AE, (eds.): Developing Grounded Theory: The Second Generation. 2009, Walnut Creek, CA, USA: Left Coast Press

Carter SM: Enacting Internal Coherence as a Path to Quality in Qualitative Inquiry. Researching Practice: A Discourse on Qualitative Methodologies. Edited by: Higgs J, Cherry N, Macklin R, Ajjawi R. 2010, Practice, Education, Work and Society Series. Rotterdam: Sense Publishers, 2: 143-152.

Wasserman JA, Clair JM, Wilson KL: Problematics of grounded theory: innovations for developing an increasingly rigorous qualitative method. Qual Res. 2009, 9: 355-381. 10.1177/1468794109106605.

Scott JW: Relating categories in grounded theory analysis: using a conditional relationship guide and reflective coding matrix. The Qualitative Report. 2004, 9 (1): 113-126.

Sarker S, Lau F, Sahay S: Using an adapted grounded theory approach for inductive theory about virtual team development. Data Base Adv Inf Sy. 2001, 32 (1): 38-56.

LaRossa R: Grounded theory methods and qualitative family research. J Marriage Fam. 2005, 67 (4): 837-857. 10.1111/j.1741-3737.2005.00179.x.

Kendall J: Axial coding and the grounded theory controversy. WJNR. 1999, 21 (6): 743-757.

CAS   PubMed   Google Scholar  

Dickson-Swift V, James EL, Kippen S, Liamputtong P: Doing sensitive research: what challenges do qualitative researchers face?. Qual Res. 2007, 7 (3): 327-353. 10.1177/1468794107078515.

Charmaz K: Discovering chronic illness - using grounded theory. Soc Sci Med. 1990, 30,11: 1161-1172.

Curtis B, Evans RW, Sbaraini A, Schwarz E: The Monitor Practice Programme: is non-surgical management of tooth decay in private practice effective?. Aust Dent J. 2008, 53: 306-313. 10.1111/j.1834-7819.2008.00071.x.

Article   CAS   PubMed   Google Scholar  

Featherstone JDB: The caries balance: The basis for caries management by risk assessment. Oral Health Prev Dent. 2004, 2 (S1): 259-264.

PubMed   Google Scholar  

Axelsson P, Nyström B, Lindhe J: The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. J Clin Periodontol. 2004, 31: 749-757. 10.1111/j.1600-051X.2004.00563.x.

Sbaraini A, Evans RW: Caries risk reduction in patients attending a caries management clinic. Aust Dent J. 2008, 53: 340-348. 10.1111/j.1834-7819.2008.00076.x.

Pitts NB: Monitoring of caries progression in permanent and primary posterior approximal enamel by bitewing radiography: A review. Community Dent Oral Epidemiol. 1983, 11: 228-235. 10.1111/j.1600-0528.1983.tb01883.x.

Pitts NB: The use of bitewing radiographs in the management of dental caries: scientific and practical considerations. DentoMaxilloFac Rad. 1996, 25: 5-16.

Article   CAS   Google Scholar  

Pitts NB: Are we ready to move from operative to non-operative/preventive treatment of dental caries in clinical practice?. Caries Res. 2004, 38: 294-304. 10.1159/000077769.

Tan PL, Evans RW, Morgan MV: Caries, bitewings, and treatment decisions. Aust Dent J. 2002, 47: 138-141. 10.1111/j.1834-7819.2002.tb00317.x.

Riordan P, Espelid I, Tveit A: Radiographic interpretation and treatment decisions among dental therapists and dentists in Western Australia. Community Dent Oral Epidemiol. 1991, 19: 268-271. 10.1111/j.1600-0528.1991.tb00165.x.

Espelid I, Tveit A, Haugejorden O, Riordan P: Variation in radiographic interpretation and restorative treatment decisions on approximal caries among dentists in Norway. Community Dent Oral Epidemiol. 1985, 13: 26-29. 10.1111/j.1600-0528.1985.tb00414.x.

Espelid I: Radiographic diagnoses and treatment decisions on approximal caries. Community Dent Oral Epidemiol. 1986, 14: 265-270. 10.1111/j.1600-0528.1986.tb01069.x.

Evans RW, Pakdaman A, Dennison P, Howe E: The Caries Management System: an evidence-based preventive strategy for dental practitioners. Application for adults. Aust Dent J. 2008, 53: 83-92. 10.1111/j.1834-7819.2007.00004.x.

Blumer H: Symbolic interactionism: perspective and method. 1969, Berkley: University of California Press

Sturges JE, Hanrahan KJ: Comparing telephone and face-to-face qualitative interviewing: a research note. Qual Res. 2004, 4 (1): 107-18. 10.1177/1468794104041110.

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Acknowledgements

We thank dentists, dental practice staff and patients for their invaluable contributions to the study. We thank Emeritus Professor Miles Little for his time and wise comments during the project.

The authors received financial support for the research from the following funding agencies: University of Sydney Postgraduate Award 2009; The Oral Health Foundation, University of Sydney; Dental Board New South Wales; Australian Dental Research Foundation; National Health and Medical Research Council Project Grant 632715.

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Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia

Alexandra Sbaraini, Stacy M Carter & Anthony Blinkhorn

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Alexandra Sbaraini, R Wendell Evans & Anthony Blinkhorn

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Correspondence to Alexandra Sbaraini .

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The authors declare that they have no competing interests.

Authors' contributions

All authors have made substantial contributions to conception and design of this study. AS carried out data collection, analysis, and interpretation of data. SMC made substantial contribution during data collection, analysis and data interpretation. AS, SMC, RWE, and AB have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.

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12874_2011_640_moesm1_esm.doc.

Additional file 1: Initial interview schedule for dentists and dental practice staff. file containing initial interview schedule for dentists and dental practice staff. (DOC 30 KB)

12874_2011_640_MOESM2_ESM.DOC

Additional file 2: Questions added to the initial interview schedule for dentists and dental practice staff. file containing questions added to the initial interview schedule (DOC 26 KB)

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Additional file 3: Questions added to the modified interview schedule for dentists and dental practice staff. file containing questions added to the modified interview schedule (DOC 26 KB)

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Sbaraini, A., Carter, S.M., Evans, R.W. et al. How to do a grounded theory study: a worked example of a study of dental practices. BMC Med Res Methodol 11 , 128 (2011). https://doi.org/10.1186/1471-2288-11-128

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A Guide to Writing a Qualitative Systematic Review Protocol to Enhance Evidence-Based Practice in Nursing and Health Care

Affiliations.

• 1 PhD candidate, School of Nursing and Midwifey, Monash University, and Clinical Nurse Specialist, Adult and Pediatric Intensive Care Unit, Monash Health, Melbourne, Victoria, Australia.
• 2 Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
• 3 Senior Lecturer, School of Nursing and Midwifery, Monash University, Melbourne, Victoria, Australia.
• PMID: 26790142
• DOI: 10.1111/wvn.12134

Background: The qualitative systematic review is a rapidly developing area of nursing research. In order to present trustworthy, high-quality recommendations, such reviews should be based on a review protocol to minimize bias and enhance transparency and reproducibility. Although there are a number of resources available to guide researchers in developing a quantitative review protocol, very few resources exist for qualitative reviews.

Aims: To guide researchers through the process of developing a qualitative systematic review protocol, using an example review question.

Methodology: The key elements required in a systematic review protocol are discussed, with a focus on application to qualitative reviews: Development of a research question; formulation of key search terms and strategies; designing a multistage review process; critical appraisal of qualitative literature; development of data extraction techniques; and data synthesis. The paper highlights important considerations during the protocol development process, and uses a previously developed review question as a working example.

Implications for research: This paper will assist novice researchers in developing a qualitative systematic review protocol. By providing a worked example of a protocol, the paper encourages the development of review protocols, enhancing the trustworthiness and value of the completed qualitative systematic review findings.

Linking evidence to action: Qualitative systematic reviews should be based on well planned, peer reviewed protocols to enhance the trustworthiness of results and thus their usefulness in clinical practice. Protocols should outline, in detail, the processes which will be used to undertake the review, including key search terms, inclusion and exclusion criteria, and the methods used for critical appraisal, data extraction and data analysis to facilitate transparency of the review process. Additionally, journals should encourage and support the publication of review protocols, and should require reference to a protocol prior to publication of the review results.

Keywords: guidelines; meta synthesis; qualitative; systematic review protocol.

© 2016 Sigma Theta Tau International.

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Qualitative Research Proposal

Proposal maker.

Writing a qualitative research proposal is just like writing any other research proposals. The only thing is that you are writing specifically designed to provide non-numerical data, concepts and the like. You are more likely to follow a specific format since it is a type of academic writing.

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What is a Qualitative Research Proposal?

A qualitative research proposal gives the detailed summary of your research study. It is a type of research proposal that only involves qualitative methods of gathering a certain data such as an interview, observation, questionnaire, or case studies . Qualitative research can be applied in the field of psychology, social sciences and the like.

How to Write a Qualitative Research Proposal?

Think of a unique topic for you to provide a good research title.

Example: A Qualitative Study on Coping up with the Different Levels of Anxiety among Students

Develop Research Questions

Your research questions will be your guide in your research study. It contains the research design, research methodology and the technique you used in collecting data.

Example: What do the architecture and engineering students with anxiety do to cope up with their studies in the university?

For qualitative research, we can use the SPIDER method which stands for Sample, Phenomenon of Interest, Design, Evaluation and Research type.

Sample refers to your target population that is included in your study.

Example: The population consisted of a community of architecture and engineering students of the oldest university in the city of Manila, Philippines.

Phenomenon of Interest refers to an event or an object. What could be their experience in the university?

Design refers to the methods you used in conducting the study.

•         Interview – refers to the one on one interaction with the participant.
•       Observation – refers to observing the participants whether or not they are fully aware of the thought that you are observing them.
•     Questionnaire – refers to the process of distributing survey questionnaires to gather answers from your participants. It ends with tallying the answers to see what the participants choose the most.
•         Case study – refers to an intensive study about a specific person or group of people.

Ensure That Some Ethical Standards are Met

This refers to protecting the privacy or confidentiality of the data you have gathered and the rights of the participants.

“There were more ethical considerations in almost all aspects for drug trials and clinical studies compared with proposals for epidemiological studies. Clinical research studies usually directly involve human subjects, either with preventive, therapeutic, or non-therapeutic procedures. In general, the study procedures in such study designs put human subjects at higher risks, thus there are more ethical concerns. The primary ethical considerations of clinical studies are competent medical treatment and care, alongside an acceptable risk–benefit balance. However, many laboratory research studies use stored specimens, with less invasive procedures, and epidemiology studies usually employ data collection through medical records, CRFs or questionnaires. Ethical issues for the latter, therefore, mainly concern confidentiality and privacy of the study participants. However, it was found that studies that collect new specimens received more comments on ethical issues. There remains debate among RECs about solutions for issues around sample export, storage, and reuse. However, it is recommended that in order to ensure adequate protection of human research subjects participating in scientific research, RECs bear the responsibility of guaranteeing that participants are provided with sufficient detail to be able to provide informed consent as well as to understand the reality of genetic research as it is practiced.”

www.ncbi.nlm.nih.gov

Consider writing a plan to be used for the whole duration of your research. this includes the timeline and budget..

Timeline – refers to the target length of time to complete your research.

Budget – refers to the estimation of how much your research would cost. All items that you think might be included in the budgeting must be included.

Don’t Forget to Include Your Reference

This contains the list of the sources that you should cite on the last page of your research. It usually follows the APA format.

How long should a qualitative research proposal be?

Every research proposal should be at least 4 to 7 pages long or depending on the requirement of your professor.

Do we still have to write for the definition of terms in the research proposal?

Yes. You have the option to do so to introduce and define words that are difficult for the readers to understand.

What can be considered as a good topic in writing qualitative research?

Your topic will either be given by your professor or you may look into unique topics into the internet.

Text prompt

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• Professional

Generate a proposal for a new school recycling program

Compose a proposal for a school field trip to a science museum.

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