Introduction to qualitative research

Mark Toles and Julie Barroso

Learning outcomes

After reading this chapter, the student should be able to do the following:

• Describe the components of a qualitative research report.

• Describe the beliefs generally held by qualitative researchers.

• Identify four ways qualitative findings can be used in evidence-based practice.

inclusion and exclusion criteria

Go to Evolve at http://evolve.elsevier.com/LoBiondo/ for review questions, critiquing exercises, and additional research articles for practice in reviewing and critiquing.

Let’s say that you are reading an article that reports findings that HIV-infected men are more adherent to their antiretroviral regimens than HIV-infected women. You wonder, “Why is that? Why would women be less adherent in taking their medications? Certainly, it is not solely due to the fact that they are women.” Or you are working in a postpartum unit and have just discharged a new mother who has debilitating rheumatoid arthritis. You wonder, “What is the process by which disabled women decide to have children? How do they go about making that decision?” These, like so many other questions we have as nurses, can be best answered through research conducted using qualitative methods. Qualitative research gives us the answers to those difficult “why?” questions. Although qualitative research can be used at many different places in a program of research, you can most often find it answering questions we have when we understand very little about some phenomenon in nursing.

What is qualitative research?

Qualitative research is a broad term that encompasses several different methodologies that share many similarities. Qualitative studies help us formulate an understanding of a phenomenon. While qualitative research has a long history in the social sciences, it is only within the past two decades that it has become more accepted in nursing research. For many years, nursing students in doctoral programs were dissuaded from conducting qualitative studies; the push was for the traditional quantitative approach, which was viewed by many as being more prestigious to those in the “hard” sciences. So as nursing gained its foothold in academics, doctoral students were urged to study using the quantitative paradigm, or worldview, to help nursing research gain legitimacy in academe. Today there is a new generation of nurse scholars who are trained in qualitative methods, and who encourage students to use methods that best answer their research questions, as opposed to ones that might add a veneer of scientific legitimacy to its conduct, but do not answer the research question at hand.

Qualitative research is discovery oriented; that is, it is explanatory, descriptive, and inductive in nature. It uses words, as opposed to numbers, to explain a phenomenon. Qualitative research lets us see the world through the eyes of another—the woman who struggles to take her antiretroviral medication, or the woman who has carefully thought through what it might be like to have a baby despite a debilitating illness. Qualitative researchers assume that we can only understand these things if we consider the context in which they take place, and this is why most qualitative research takes place in naturalistic settings. Qualitative studies make the world of an individual visible to the rest of us. Qualitative research involves an “interpretative, naturalistic approach to the world; meaning that qualitative researchers study things in their natural settings, attempting to make sense of or interpret phenomena in terms of the meaning people bring to them” (Denzin & Lincoln, 2011, p. 3).

What do qualitative researchers believe?

Qualitative researchers believe that there are multiple realities that can be understood by carefully studying what people can tell us or what we can observe as we spend time with them. For example, the experience of having a baby, while it has some shared characteristics, is not the same for any two women, and is definitely different for a disabled mother. Thus, qualitative researchers believe that reality is socially constructed and context dependent. Even the experience of reading this book is different for any two students; one may be completely engrossed by the content, while another is reading, but is worrying about whether or not her financial aid will be approved soon (Fig. 5-1).

FIGURE 5-1 Shifting perspectives: seeing the world as others see it. (GARFIELD, © 1983 Paws, Inc. Reprinted with permission of Universal Press Syndicate. All rights reserved.)

Because qualitative researchers believe that the discovery of meaning is the basis for knowledge, their research questions, approaches, and activities are often quite different from quantitative researchers (see the Critical Thinking Decision Path). Qualitative researchers, for example, seek to understand the “lived experience” of the research participants. They might use interviews or observations to gather new data, and use new data to create narratives about research phenomena. Thus, qualitative researchers know that there is a very strong imperative to clearly describe the phenomenon under study. Ideally, the reader of a qualitative research report, if even slightly acquainted with the phenomenon, would have an “aha!” moment in reading a well-written qualitative report.

CRITICAL THINKING DECISION PATH

Selecting a Research Process

So, you may now be saying, “Wow! This sounds great! Qualitative research is for me!” Many nurses feel very comfortable with this approach because we are educated with regard to how to talk to people about the health issues concerning them; we are used to listening, and listening well. But the most important consideration for any research study is whether or not the methodology fits the question. This means that qualitative researchers must select an approach for exploring phenomena that will actually answer their research questions. Thus, as you read studies and are considering them as evidence on which to base your practice, you should ask yourself, “Does the methodology fit with the research question under study?”

HELPFUL HINT

All research is based on a paradigm, but this is seldom specifically stated in a research report.

Does the methodology fit with the research question being asked?

As we said before, qualitative methods are often best for helping us to determine the nature of a phenomenon and the meaning of experience. Sometimes, authors will state that they are using qualitative methods because little is known about a phenomenon; that alone is not a good reason for conducting a study. Little may be known about a phenomenon because it does not matter! For researchers to ask people to participate in a study, to open themselves and their lives to us, they should be asking about things that will help to make a difference in people’s lives or in how to provide more effective nursing care. You should be able to articulate a valid reason for conducting a study, beyond “little is known ….”

In the examples at the start of this chapter, we would want to know why HIV-infected women are less adherent to their medication regimens, so we can work to change these barriers and anticipate them when our patients are ready to start taking these pills. Similarly, we need to understand the decision-making processes women use to decide whether or not to have a child when they are disabled, so we can guide or advise the next woman who is going through this process. To summarize, we say a qualitative approach “fits” a research question when the researchers seek to understand the nature or experience of phenomena by attending to personal accounts of those with direct experiences related to the phenomena. Next, let’s discuss the parts of a qualitative research study.

Components of a qualitative research study

The components of a qualitative research study include the review of literature, study design, study setting and sample, approaches for data collection and analysis, study findings, and conclusions with implications for practice and research. As we reflect on these parts of qualitative studies, we will see how nurses use the qualitative research process to develop new knowledge for practice (Box 5-1).

BOX 5-1 STEPS IN THE RESEARCH PROCESS

• Review of the literature

• Study design

• Sample

• Setting: recruitment and data collection

Review of the literature

When researchers are clear that a qualitative approach is the best way to answer the research question, their first step is to review the relevant literature and describe what is already known about the phenomena of interest. This may require creativity on the researcher’s part, because there may not be any published research on the phenomenon in question. Usually, there are studies on similar subjects, or with the same patient population, or on a closely related concept. For example, researchers may want to study how women who have a disabling illness make decisions about becoming pregnant. While there may be no other studies in this particular area, there may be some on decision-making in pregnancy when a woman does not have a disabling illness. These studies would be important in the review of the literature because they identify concepts and relationships that can be used to guide the research process. For example, findings from the review can show us the precise needs for new research, what participants should be in the study sample, and what kinds of questions should be used to collect the data.

Let’s consider an example. Say a group of researchers wanted to examine HIV-infected women’s adherence to antiretroviral therapy. If there was no research on this exact topic, the researcher might examine studies on adherence to therapy in other illnesses, such as diabetes or hypertension. They might include studies that examine gender differences in medication adherence. Or they might examine the literature on adherence in a stigmatizing illness, or look at appointment adherence for women, to see what facilitates or acts as a barrier to attending health care appointments. The major point here is that even though there may be no literature on the phenomena of interest, the review of the literature will identify existing related data that are useful for exploring the new questions. At the conclusion of an effective review, you should be able to easily identify the strengths and weaknesses in prior research; you should also have a clear understanding of the new research questions as well as the significance of studying them.

Study design

The study design is a description of how the qualitative researcher plans to go about answering the research questions. In qualitative research, there may simply be a descriptive or naturalistic design in which the researchers adhere to the general tenets of qualitative research, but do not commit to a particular methodology. There are many different qualitative methods used to answer the research questions. Some of these methods will be discussed in the next chapter. What is important, as you read from this point forward, is that the study design must be congruent with the philosophical beliefs that qualitative researchers hold. You would not expect to see a qualitative researcher use methods common to quantitative studies, such as a random sample or battery of questionnaires administered in a hospital outpatient clinic or a multiple regression analysis. Rather, you would expect to see a design that includes participant interviews or observation, strategies for inductive analysis, and plans for using data to develop narrative summaries with rich description of the details from participants’ experiences (see Fig. 5-1). You may also read about a pilot study in the description of a study design; this is work the researchers did before undertaking the main study to make sure that the logistics of the proposed study were reasonable. For example, pilot data may describe whether the investigators were able to recruit participants and whether the research design led them to information they needed.

Sample

The study sample refers to the group of people that the researcher will interview or observe in the process of collecting data to answer the research questions. In most qualitative studies, the researchers are looking for a purposeful or purposively selected sample (see Chapter 10). This means that they are searching for a particular kind of person who can illuminate the phenomenon they want to study. For example, the researchers may want to interview women with multiple sclerosis, or rheumatoid arthritis. There may be other parameters—called inclusion and exclusion criteria—that the researchers impose as well, such as requiring that participants be older than 18 years, or not using illicit drugs, or deciding about a first pregnancy (as opposed to subsequent pregnancies). When researchers are clear about these criteria, they are able to identify and recruit study participants with experiences needed to shed light on the phenomenon in question. Often the researchers make decisions such as determining who might be a “long-term survivor” of a certain illness. In this case, they must clearly understand why and how they decided who would fit into this category. Is a long-term survivor someone who has had an illness for 5 years? Ten years? What is the median survival time for people with this diagnosis? Thus, as a reader of nursing research, you are looking for evidence of sound scientific reasoning behind the sampling plan.

When the researchers have identified the type of person to include in the research sample, the next step is to develop a strategy for recruiting participants, which means locating and engaging them in the research. Recruitment materials are usually very specific. For example, if the researchers want to talk to HIV-infected women about adherence, they may distribute flyers or advertise their interest in recruiting women who are adherent, as well as those who are not. Or, they may want to talk to women who fit into only one of those categories. Similarly, the researchers who are examining decision making in pregnancy among women with disabling conditions would develop recruitment strategies that identify subjects with the conditions or characteristics they want to study.

In a research report, the researcher may include a description of the study sample in the findings (it can also be reported in the description of the sample). In any event, besides a demographic description of the study participants, a qualitative researcher should also report on key axes of difference in the sample. For example, in a sample of HIV-infected women, there should be information about stage of illness, what kind/how many pills they must take, how many children they have, and so on. This information helps you place the findings into some context.

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