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Objectivity, in a complete and unbiased sense, is not something that can be achieved by any scientist, or by any human being, nor is it necessarily desirable in every situation. The mere identification of something as a problem involves judgment on the part of the researcher. The researcher’s existing biases are integrated throughout the conduct of inquiry and, in fact, often are useful in the research situation as they provide the researcher with important tools for research such as language, concepts, theories, and mechanisms for interacting with human subjects of study. These are all biases in a sense, yet research would not be possible without them. Complete objectivity, therefore, is not possible without dispensing with all that has been learned through both education and development in a social context and without dispensing with some basic facts of how human beings function. Rather than seeing the possibility of one absolute answer or truth, objectivity, and control as necessary ingredients for science, recent philosophers of science (those who explore what makes science work and what constitutes good science) provide a contemporary view of science as an attempt to solve problems, to generate solutions that work, to exercise creativity and innovation in the interest of discovery and development of knowledge, and to tie research to a broad interest in the good of society (Rodgers, 2005). Outcomes of science sometimes point to what it is appropriate to do in a situation. In other cases, they point to enlightening and empowering people to be active participants in their own lives and health-related situations. This shift in perspective is associated with a philosophy known as postmodernism, and the growth of such research spurred energetic debate about the evidence in general and various ranking systems earlier in the movement toward EBP (Porter & O’Halloran, 2009).

The evolving idea of what constitutes science fueled a substantial increase in the acceptance and, consequently, the volume of qualitative research being conducted in a variety of disciplines. Qualitative research, although a mainstay of inquiry in the social sciences for more than a century, ultimately blossomed in acceptance and use in a broad array of disciplines. In nursing, evidence of considerable growth in this area can be seen starting particularly in the 1980s, although 175there was some discussion of its utility even earlier than that. Quint (1967), for example, produced a seminal work demonstrating the importance of qualitative research in theory development at the dawning of the theory movement in nursing, decades before qualitative research developed any noticeable foothold in nursing. Acceptance of such methods in the research enterprise was slow at first, but it has become an essential aspect of nursing’s knowledge base, providing valuable information on aspects of human health and illness that are best explored using the capabilities of qualitative methods. The role of qualitative research results in regard to evidence-based practice is still the subject of some debate, although qualitative research appears on Level of Evidence tables with increasing regularity (Melnyk & Fineout-Overholt, 2019) and there is no question that nurses understand the importance of patient experiences in determining the appropriateness of various interventions and practices in healthcare. It is the relationship that nurses develop with people in the context of health and wellness that differentiates nursing care from other aspects of health and illness work. These connections with individuals and groups create a strong need for evidence and a scientific base such as is obtained through qualitative research.

■ WHY QUALITATIVE RESEARCH?

As noted previously, qualitative research is appropriate for inquiry that addresses a number of aspects relevant to nursing and provides an important part of the evidence base essential to nursing practice. Qualitative research approaches the study of phenomena in a natural setting. Rather than attempt to control elements of the research situation, such as by manipulating variables (e.g., an intervention presented in a controlled setting), a qualitative study typically is designed to capture experiences or events as they naturally occur. Qualitative research also excels at capturing people’s thoughts and feelings, which are not easily reduced to numbered responses to questions on paper and pencil instruments. Qualitative research offers insights important to viewing situations and people holistically and, therefore, is ideal to answer broad questions that warrant in-depth description. Some examples of research questions that might be used for qualitative studies are provided in Box 10.1.

The broad questions presented in the samples reveal some of the specific purposes and functions of qualitative research. Qualitative research can be used to describe, providing both a deep and rich description of a situation or experience. Qualitative research also helps to provide information about aspects that might be missed with a quantitative study. For example, quantitative research is appropriate for determining if one intervention is more effective than another in a way that is statistically significant. Such a study, however, will not provide information about what it is like for an individual to live with the intervention. In such a situation, qualitative research makes it possible to capture information that is essential to gaining a complete picture of a situation or experience. Qualitative research can also be very sensitizing, raising awareness of aspects of an 176experience that might not have been recognized previously. By doing so, nurses are better able to anticipate patients’ needs and concerns and understand their perspectives when confronted with a health-related situation. Obviously knowledge of these types is important for nursing practice where nurses need to be able to individualize care and work with psychological, social, and emotional aspects as well as the physiologic components of health and illness situations. Qualitative research is ideal for understanding what people think, feel, believe, and live through as they encounter situations related to their health and well-being.

As noted earlier, qualitative research typically is focused on words as data rather than numbers and the qualitative researcher reports results in the form of words. Some qualitative studies also 177can involve other forms of communication such as dramatizations or the use of photos. There has been considerable growth in the use of visual forms of data and of expression, although such research is much less common than research focused on verbal accounts (Banks, 2018). Even in cases of visually oriented research, word descriptions typically accompany and elucidate the other components of data. In spite of this common characteristic among all the qualitative approaches, there are distinct methodologies for qualitative research, each of which has its own unique philosophical underpinnings, history, and procedures for the conduct of a study.

On a very basic level, there is a general type of qualitative research that often appears in the literature. A study might be described as merely “qualitative,” “descriptive,” “qualitative descriptive,” “exploratory,” “naturalistic,” “field research,” or “ethnographic.” All of these refer to the collection of data directly from subjects (referred to as participants in acknowledgment of their active role in the process) and are typically in the form of words. Such studies are similar in that they tend to rely on either individual or group interviews and, occasionally, observation, and general forms of analysis that identify patterns and similarities in the data. Qualitative studies can be conducted quite well without being associated with a more specific methodology that has unique requirements regarding the question and the collection and analysis of data. Note that descriptive research can be quantitative as well, so seeing a study characterized as “descriptive” in a report of research requires a closer look at the nature of the data and the report of results to determine if it is qualitative or quantitative. The term “ethnographic,” similarly, can have multiple meanings, referring most generally to research in a natural setting. There also is a distinct methodology known as ethnography, which is discussed later.

More specific methodologies for qualitative research are found in the literature. In nursing, some of the more common types of qualitative studies are grounded theory, phenomenology, hermeneutic (most often hermeneutic phenomenology), narrative inquiry, and, as noted earlier, ethnography. A brief definition of each of these primary methodologies is provided in Table 10.1.

Grounded theory research was introduced formally in the 1960s based on the work of noted sociologist Anselm Strauss and colleague Barney Glaser (Glaser & Strauss, 1967). This method is guided by the theoretical viewpoint of symbolic interactionism (Blumer, 1969), although the essential nature of the link to symbolic interactionism has been questioned in recent years. In general, symbolic interactionism holds that people create their sense of self, their reality, societies, 178and so on, through interaction with other people. How an individual experiences some event or process in life is heavily influenced by those interactions. In a grounded theory study, the researcher seeks information about the overall experience of people in specific situations of interest to the researcher. The researcher conducting an investigation using the methodology of grounded theory will have a research question such as “what is it like to . . .” or “what is the experience of people with. . . . ” The experience that is the focus of research will involve the thoughts, feelings, actions, interactions with others, and interpretations of events associated with the situation being studied as described by the people who are going through that experience.

Grounded theory research has a unique end product in that it is used to construct a substantive theory that provides a detailed depiction of the experience being studied that is derived from (grounded in) the data obtained from participants. This theory is organized around a central idea referred to as the core variable (Charmaz, 2014; Glaser, 1978; Glaser & Strauss, 1967), which represents the primary focus of the experience. This core variable represents the Basic Sociopsychological Process involved in the experience and reflects the symbolic interactionism foundation regarding interaction being important in the shaping of experience. Since Glaser and Strauss pioneered this method in the late 1960s, other variations have been introduced, including a version by Strauss and Corbin (1998). The underlying principles are the same, although the Strauss and Corbin version imposes more structure on the data analysis process and on the reporting of results. Other adaptations have been created as well, most notably the constructivist orientation provided by Charmaz (Bryant & Charmaz, 2019; Charmaz, 2000, 2005, 2008, 2014). From the standpoint of the advanced practice nurse who needs to critique and evaluate research for implications for practice, reports of grounded theory studies can be evaluated similarly, keeping in mind the foundations of this approach and the expected outcome of a substantive theory, regardless of the specific variation a researcher used in a study.

The qualitative method known as phenomenology is also used to study experiences, but is focused on the meaning of the lived experience of the people in the study. Phenomenology was derived originally from the philosophies of Edmund Husserl (1960) and Merleau-Ponty (1962/1999), and its origins contributed to the extensive foundation in philosophy that is evident in this method. Based on this foundation, modifications to the method were presented by existentialist philosopher Martin Heidegger, and the method was adapted further as a means of study in psychology. There are numerous unique approaches that are all justifiably referred to as phenomenology, including a variation called hermeneutic phenomenology (Crowther et al., 2017; Matua & Van Der Wal, 2015; Spence, 2017), which is fairly common in nursing. All of these approaches have some elements in common, however. Whereas grounded theory is focused on social interaction and processes, phenomenology is a method to study the individual and how the individual ascribes meaning to an experience. A significant underpinning of this research method is the idea that humans create their own realities and these realities, in turn, have a strong influence on creating the individual. This idea is referred to as co-constitution, capturing the notion that people, and their realities have an influence on the construction of each other. Experiences and events have their own essence or what might in common language be referred to as the facts of the situation, or what actually happened. A person is diagnosed with a chronic illness, for example, and there is solid evidence to support that diagnosis and the fact that it was communicated to the individual. In phenomenology, however, the focus is on the layers of meaning or interpretation that the individual gives to the situation. It is not even necessary that there be facts to support the interpretation.

As an example for phenomenology, consider an individual who has a family history of a condition associated with cognitive decline. That person might have occasional feelings of being 179distracted or forgetting to do a particular task and interprets those as a symptom of the impending hereditary decline, even though there is no substantive or documented reason to make that association. The interpretation or meaning the individual assigns to what he or she is experiencing will have a profound influence on the sense of self and the willingness to share the experiences with others. While all qualitative methods are focused on people’s experiences and their own individual realities, the phenomenological researcher typically goes beyond the actual words spoken by an individual to describe the experience in an attempt to interpret these words and identify underlying meaning. For that reason, phenomenology sometimes is referred to as an interpretive method (Horrigan-Kelly et al., 2016; Van Manen, 1997) rather than a descriptive one. The product of phenomenological research is a discussion of significant ideas or meaning statements derived through analysis of the participant’s words and interpretation of the meanings the experience being studied has for the individual. Phenomenology is a complex and highly variable qualitative method and the sample sizes, analytic approaches, and results will differ depending on the particular orientation employed by the researcher.

Narrative inquiry is another form of qualitative research that is common in nursing. Narrative inquiry (Clandinin, 2020; Holstein & Gubrium, 2012; Riessman, 1993) is grounded in the premise that people typically construct stories about their various life experiences including stories that form their own identities. These stories represent the individual’s way of weaving together elements of the event into their story of their experience. According to Riessman (1993), the purpose of narrative inquiry is “to see how respondents in interviews impose order on the flow of experience to make sense of events and actions in their lives” (p. 2). These stories involve all the typical aspects of a story including players, supporting players, settings, sequencing of events, and outcomes. Using the techniques of narrative analysis, the researcher examines these stories to uncover an underlying narrative that characterizes the stories associated with an experience (Riley & Hawe, 2005). Narrative inquiry emphasizes the dimensions of temporality, sociality, and place in gaining understanding of an experience. According to this methodology, events involve a temporal timeline, or a past, present, and future. Sociality refers to the interplay of personal and social aspects of experience. This includes personal elements of feelings and hopes as well as cultural and social conditions. The relationship that develops between the researcher and the participants also is a part of the experience. Finally, the element of place refers to physical boundaries (Connelly & Clandinin, 2006). These elements are not considered on their own; for example, a simple reporting of when or where something happened. Instead, these are considered to be related components of the complex experiences in people’s lives. These elements are interwoven in the stories people create about their lives and the way they use language to construct these narratives.

The final form of qualitative research that will be discussed here is ethnography. Ethnography as a specific method (in contrast to the more generic use of the term “ethnographic” to refer to research that takes place in a natural setting or in the field) originated in the discipline of anthropology. Ethnography is focused on the study of culture. For purposes of this type of research, a culture is “the total way of life of a group and the learned behavior that is socially constructed and transmitted” (Wolf, 2012, p. 295). In conducting research using the methodology of ethnography, the researcher typically spends extensive time in the setting being studied. In addition to “getting in,” the process of becoming accepted by the group being studied, a goal in the early phase of such a study is the identification of key informants or people who are particularly familiar with the setting or experience and whose perspectives are important to understanding the workings of the setting. The researcher will observe the group and interactions among the group, keep extensive notes, and talk with individuals in addition to the key informants whose input is particularly important to the study. Ethnographies are found much less frequently in the nursing literature 180than are examples of the other methods, perhaps because of the extremely time-intensive nature of the research. In addition, ethnographies typically are so extensive and detailed that they can be reported only partially through the usual format of a journal article.

■ CONDUCTING A QUALITATIVE STUDY

Before attempting the critical evaluation of qualitative studies, it is necessary to understand how qualitative research is conducted. In spite of the differences in the foundation and the development of the various traditions, the overall procedures for conducting a qualitative study are quite similar. Those procedures differ considerably from those used in conducting quantitative studies (Wu et al., 2016), and a review of the steps in the process, comparing qualitative and quantitative types of research, can be helpful to identify important differences.

It is important to remember that the intent in any type of qualitative research is to capture the individual realities of the participants and to provide a detailed description of those realities and the experiences of the people studied. Therefore, elements of research that involve ideas such as control, theoretical frameworks, hypothesis testing, reliability, and generalizability, for example, are either inappropriate or take on an entirely different meaning in the context of a qualitative study. The following sections describe the sequence of steps typically pursued in conducting a qualitative study. Ideas about what to look for in the critique of qualitative studies are included as well to develop skill in assessing the quality of published reports of qualitative research.

Research Problem and Question

As with any type of research, the process of qualitative inquiry begins with identification of a problem and a research question. Problems appropriate for qualitative research exist when there are new ideas or situations to explore and little is known about the phenomenon. In such a situation, studies aimed at broad discovery are appropriate. A change in a treatment modality might warrant a study that explores the experiences of people who receive that treatment; staffing patterns for nurses might be explored in regard to the experiences of the nurses who live with that pattern on a regular basis or might lead to exploration of other aspects of the care delivered by the nursing staff. Problems appropriate for qualitative research also exist when there are significant gaps in knowledge. A long-standing procedure might have been studied extensively regarding its effectiveness, yet there may be very little information about what patients think or feel about the treatment and how it affects their daily lives. A problem amenable to qualitative research can be just about anything that can be answered through in-depth discovery and descriptions of the experiences, thoughts, and feelings of people who have encountered the situation being studied.

Questions for qualitative studies appear to be similar in spite of the specific tradition of inquiry that underlies the research. There are subtle differences in wording, however, that clue the reader as to the specific tradition being explored. Phenomenology, for example, involves the phrase “lived experience” or the word “meaning” as a specific focus of the research question for that type of study. Beyond some seemingly minor variations in wording, questions for a qualitative study in general address the broad experience or the reactions (including thoughts, feelings, interpretations, and meanings) regarding a life encounter.

Researchers often do not state a specific research question in their report of qualitative studies; the absence of an actual question is not a weakness in a research report. The purpose of the study and the problem situation that led to the development of the research, however, should be clear to the reader and, ideally, these are presented early in the published report. The question or 181problem should be one that is appropriate to qualitative inquiry as well. Questions about what should be done in a situation or what is better are not amenable to any type of research as they call for judgments that go beyond the actual data gained through the study. A researcher can, however, address a question about what people report, what characteristics are identified, how people describe their feelings, and how they live with some situation or experience as a step toward developing conclusions about what is better and why that is the case.

Review of Literature

Another step in the typical research process involves a review of the literature. It is a bit misleading to consider this a separate step, as with any type of study the review of the literature can be very helpful in refining the original problem. The iterative process of reviewing the literature and rethinking the original problem helps the researcher to gain clarity and important perspectives that give direction to the subsequent research. In a quantitative study, the literature review typically provides an important foundation for the research by revealing what is already known about the situation of interest. On this basis, the researcher can determine the appropriate next steps for inquiry and, depending on the type of research, can develop a theoretical foundation for the study and possible hypotheses. At this point, qualitative and quantitative studies differ considerably. The qualitative researcher does not intend to build on existing research but typically embarks on an attempt to explore, discover, and describe areas and experiences about which little already is known. In this spirit, the researcher wants to remain as open as is plausible to the many possibilities that can exist in any situation. Using the literature review to frame the study would put some boundaries around what is explored and what might be seen in the data that are collected.

Some discussions of qualitative research present the argument that there is no need for any type of literature review before embarking on a qualitative study (Glaser & Strauss, 1967). Avoiding contact with existing information is believed to enable the researcher to be more open and unbiased about what might be encountered through the study. While the idea of being as unbiased as possible is appealing, this approach is faulty on a couple of levels. First, it is never possible to be completely open and unbiased about anything. The researcher is making judgments from the very beginning of a study by identifying something as a problem and by naming phenomena; in other words, by using certain words to label what is being studied. The researcher also inherently possesses some bias due to the researcher’s own experience as a human interacting with others and with the knowledge they already have accumulated. Individual values influence all research, so the idea of objectivity being enhanced by avoiding a literature review is not defensible; yet, this is not the same as the researcher actively seeking a foundation in the literature on which to build the new study.

Diminishing bias in a study is a desirable goal to the extent possible and typically the researcher does not want to skew the study in any particular direction to avoid placing limits on what might be discovered. Seeking possible explanations or hypotheses in the literature would add specific direction to the research that is counter to the openness that is such a strength in qualitative research. In qualitative studies, therefore, there often is a literature review but it takes on a unique form. The qualitative researcher typically does a thorough literature review prior to the start of the study, but that review is oriented toward substantiating that a problem does exist, that qualitative methods are appropriate to address that problem, and, in some cases, to gain direction and support for the methods chosen for the study. Rather than provide a foundation for the research, the literature review in a qualitative study enables the researcher to justify the need for the research and the chosen form of qualitative inquiry.

182The literature review section that appears relatively early in a report of a qualitative study should be thorough and give good background information about the problem. Since the researcher usually is not building on this existing information for further inquiry in an area, the literature review sometimes is more broad, discussing a wide variety of studies that have been done and often identifying gaps in knowledge rather than focusing on a select few items or articles to provide underpinnings for the research. Ultimately, the researcher uses the literature review to make a clear case for the fact that a researchable problem exists and that it is important to generate information that will fill this gap. As noted earlier, the appropriateness of qualitative methods to address the problem should be apparent as well.

The use of an initial literature review to substantiate the problem and methods is one difference between qualitative and quantitative studies. Similarly, in quantitative research, the initial literature review is used to tie the study to previous work, showing how the study presented in a published report relates to other research. In qualitative studies, this connection to existing work is made near the end of the study rather than at the beginning. As themes and patterns are identified in the data obtained during the study, the researcher will conduct an extensive literature review late in the conduct of the study to determine how the ideas that have been discovered relate to extant knowledge. For example, in a study of the experiences of people living with obstructive sleep apnea (OSA) (Rodgers, 2013), the researcher returned to the literature to gather information about several aspects of the experience that arose during the study. While dependence on technology associated with sleep apnea could be expected to be an issue in this study, the researcher did not find the machine aspect to be a pronounced aspect of the experience, although that has been a focus of experience with other technology-dependent conditions. People expressed some distress about having to use a mask, but expressed little concern about the role of a machine in their lives or managing the technology. The impact was felt far more in the area of adjustment to diagnosis with a chronic illness and feeling supported throughout the process. Technology-dependent conditions often come with considerable training and support which was not the case for the people in this study. This raised questions about the interconnections of variables in this study that might help to understand the different experiences. Ultimately, this led to an extensive literature review to examine associations among these concepts as a means of connecting the findings from the study with existing knowledge, particularly in regard to other conditions in which technology is a significant factor in health status. If the study had been based on a framework focused on technology, other key findings might have received much less emphasis as they might have fallen outside the framework used to explain the findings. This example demonstrates the value of a more broad and open approach in qualitative studies and what can be accomplished without a predetermined framework that narrows the inquiry.

Theories provide an important foundation and guide for research but also can place limits on how something is studied and how the results are interpreted. When reading published reports of qualitative research, the literature review component needs to be evaluated in regard to the initial review that is used to substantiate the problem as well as in the discussion section at the end of the report. In this latter section, the researcher discusses the findings of the current study in the context of previous research and theoretical literature. This use of the literature enables additional clarification of the findings of the study as well as a means to tie the findings to what is already known. As a result, there are benefits both to the current research and to expanding the knowledge base. The researcher can compare findings from the study to those already in the literature as a step toward expanding the findings as well as to demonstrate how the research contributes to what has been presented previously in the literature. The elements of any good literature review are appropriate for use in evaluating this component of a qualitative study: use of primary sources, 183evidence of a thorough search, and use of current sources that are appropriate in any literature review. The results of the literature review that is done later in the study to expand findings and make connections with existing knowledge are presented in the discussion section of the research report. In this section, the researcher is expected to use relevant literature in discussion of major findings as a means to enhance understanding of the findings and demonstrate a clear connection to prior theory and research.

■ DESIGN OF QUALITATIVE STUDIES

In qualitative studies, the researcher has a broad problem of interest and specific variables are not identified in advance. As a result, the researcher develops the design for the study based on the problem, the initial literature review, and the purpose—what the researcher intends to accomplish with the study. The typical form of design for a qualitative study is referred to as an emergent design—the design actually emerges as the study proceeds. In qualitative studies, the researcher not only has flexibility to make changes in the design but, in the course of doing the study, actually is expected to make changes in the design to pursue new ideas and areas of inquiry as they are determined to be important. It is not possible to plan all of the elements of the research design in advance and, in fact, the quality of the study often requires that some changes be made if the researcher is to do a thorough investigation of the phenomenon being studied. This is in stark contrast to how quantitative research typically is conducted. In a quantitative study the researcher plans every element of the design in advance and then follows that plan closely. In some studies, there may be minor modifications, but not of the magnitude that may be encountered in a qualitative study. In quantitative research, a pilot study often is conducted to determine if any changes in the original design are needed and the researcher generally follows the plan for the study that is created before the study actually begins.

A qualitative study, as with any research, needs a clear purpose, but the study will benefit from some flexibility in the path to achieve that purpose. This is not a limitation of qualitative research but should be seen as a benefit as it offers the opportunity to explore ideas that were not evident at the start of the study. New information, including things that the researcher could not anticipate, often arises in the course of collecting data from participants. As new information is obtained through data collection, the astute researcher will realize that there are new avenues to be explored, people with different characteristics that need to be investigated, and new questions to ask in interviews.

A study of women’s experiences with myocardial infarction conducted by the author provides an example of how unanticipated occurrences can be followed to enrich the outcome of the research. Early in this study the investigator was surprised to learn that none of the women interviewed had gone to the hospital by ambulance in spite of recognizing that they probably were having a heart attack at the time. This was an unanticipated finding and certainly something that needed to be explored to provide a meaningful and comprehensive description of the experiences of these women. Merely reporting this to be the case would have been interesting but would have been a lost opportunity for full description. The benefits of the research, also, would have been diminished considerably as what could be a key element in their experience was not explored sufficiently. Realizing this aspect of the experience, the investigator made a couple of changes in the study. The investigator began explicitly gathering information from each woman about the actual transportation to receive healthcare after recognizing she was having an MI. This constituted a change in the interview process. The researcher also added a new site for subject recruitment as 184those interviewed up to that point in the study had been in a comfortable position economically and the researcher was interested in determining whether this observation persisted in different socioeconomic groups. In one sense, this following of leads sometimes is thought of as a form of hypothesis testing; for example, does the mode of transportation to the hospital differ with socioeconomic status, age, or living situation? The ability to follow a relevant path wherever it may lead in the inquiry is important to achieving the depth and scope of understanding of the situation that is sought in qualitative research and accounts for the need for elements of design to emerge in the course of a study. It also is a good example of how it is not always clear at the start of a study what data are relevant to answer the research question. Adhering to a predetermined set of variables from the beginning of a study can result in unnecessary restrictions on what is being studied and, consequently, gaps in fully understanding the phenomenon or situation of interest.

Sample Selection

Qualitative researchers often view their research as an interactive process involving the people who are involved in a study. Rather than view them as subjects of the study, they can be thought of as having an active role in the research; this active role often involves sharing sensitive aspects of their lives and is recognized in researchers commonly referring to them as participants or informants rather than subjects. Participants help to construct the study in a way by offering information about their experiences and this information, in turn, is used by the researcher to determine the appropriate direction of the research. Although some aspects of design can change throughout the conduct of a qualitative study, many elements can be determined in advance. The specific sample typically is not determined in advance and probability samples usually are not appropriate for qualitative research. That does not mean, however, that the researcher simply takes into the study anyone who comes along and is willing to participate. The researcher must establish clear eligibility criteria for selection of participants, and these criteria typically involve competence to provide informed consent to participate, the ability to speak and understand the language of the researcher, and an adequate amount of engagement with the experience being studied. Other factors can be included as appropriate to determine eligibility for a study and there may be some differences in sampling technique and sample size across the different traditions of qualitative research, though the general approach is remarkably similar (Gentles et al., 2015).

Studying the experiences of women with MI, for example, obviously requires the participants to have experienced an MI. Similarly, for the study of people’s experiences with OSA, the people included in the study were those who had some encounter or awareness with a diagnosis of OSA. Beyond the criterion of having experience with the situation or phenomenon being studied, the researcher can impose more specific requirements appropriate to the nature of the study. The MI study was focused on women’s concurrent experiences rather than on a retrospective account of their situations. Therefore, eligibility criteria included a time frame for the occurrence of the MI relative to data collection. For this study, the participant also could not have had a diagnosis of MI previously as the researcher was interested in each woman’s experience of first becoming aware that she had experienced an MI. For the OSA study, the researcher was interested in the experience of OSA from the time of early recognition that the person might have OSA through various experiences with actual treatment. Therefore, the sampling criteria were intentionally broad to capture people at all stages of the condition including awareness, but per-diagnosis.

Because of the existence of specific criteria for eligibility, the usual sample for a qualitative study is described as purposive. Occasionally the samples are described as samples of convenience, 185meaning whoever is available, willing, and accessible to the researcher. For some studies, such a broad sampling plan may be acceptable. Many qualitative studies, however, require a sample that involves a bit more selectivity in which there are relevant and distinct criteria that enable the researcher to purposefully recruit participants who are in the best position to provide data needed for the study. Regardless of the specific type of sampling procedure employed, it is important that the qualitative researcher have participants in the study who are willing and capable of describing their experiences with the situation being studied, that those people actually have experience with the situation being studied, and that they have sufficient experience to provide meaningful descriptions and insights.

Sample size is a concern in any type of research, and qualitative research is no exception. Researchers using quantitative designs have the ability to determine appropriate sample sizes using statistical procedures such as power analysis in many cases. In qualitative research there is no ability to predict in advance precisely how many participants are needed to produce meaningful results. It is also the case that in qualitative research the amount of data that are generated has bearing on determination of the appropriate sample size. One hour of an audio-recorded interview generally produces as many as 30 pages of single-spaced transcribed text, an incredible amount of data. All of the data in an effectively conducted interview need to be analyzed. As a result, the amount of data available for analysis can be quite large with even a small group of participants. Qualitative research also can place a high demand on time and other resources. These factors in combination contribute to qualitative studies typically having relatively small sample sizes, but those smaller samples also are due to the fact that large samples are not necessary to generate meaningful and credible results due to the volume of data generated. There is no rule for what constitutes an adequate sample size in a qualitative study. Rather than counting participants, it is important that the researcher make a strong case that the study involved a considerable volume of data of high quality and that the data were sufficient to provide a cohesive and defensible answer to the research question.

Determination of an adequate sample, therefore, is based on several factors including the quantity and quality of data generated, the characteristics of the participants, the procedures employed in the study to maximize diversity in the participants and their experiences, and the ability to answer the research question with the data that are generated through the research. In planning to do a qualitative study the researcher can anticipate approximately how many people will be needed in the sample to reach this desired outcome. Because this is not an absolute number, proposals for qualitative research often include a range for the number of participants who will be recruited for the study. Published reports may show sample sizes ranging from 10 to 30 or more. In evaluating these studies, as noted earlier, there are several factors that need to be considered beyond the actual number of people involved.

A common practice in qualitative research is to use the criterion of saturation (Morse, 1991) or redundancy (Lincoln & Guba, 1985; Patton, 2001) to determine when the sample size is adequate. The word “saturation” is found in many published reports of qualitative studies with the researcher justifying the sample size by saying that saturation was achieved. Saturation typically is defined as the point at which the researcher is not hearing anything new in the data; in other words, the descriptions provided by participants are sufficiently similar that there is no need to continue with subject recruitment. For reasons that should be obvious, this can be a very troublesome criterion. First, the researcher is making a fairly bold assumption that talking with additional people will not provide anything new. Second, the failure to obtain new insights through the data collection processes that are being used could be a function of the data collection process itself and not necessarily a reflection of the experiences of the participants. If the researcher is 186asking leading questions during the interviewing or becomes fixated on certain aspects of the experience, this could lead to a premature sense that there is nothing new being learned through data collection. Finally, the researcher has to avoid the development of bias in interpreting things in a particular way. Such bias could give the false impression that there is nothing new in the data. It is important in qualitative research, as in any study, that the researcher be open to new ideas and insights that arise through data collection and analysis, and recognize that there is always the possibility of learning something new. A better justification of sample size is if the data are of high quality, the study rigorous, and the results are based on sufficient data to support that the answer to the research question is credible and comprehensive without any obvious gaps or leaps in the conclusions.

Data Collection for Qualitative Research

Any non-numerical data can be used for purposes of qualitative research. This can include notes written when making observations, a review of existing documentation and records such as patient medical records, print media such as books or popular literature, participant-generated journals or diaries, or video recordings. The majority of data collection for qualitative studies occurs through the use of interviews with individuals or in focus groups. Typically, interviews are conducted on a face-to-face basis, although telephone and email or web-based interviews with individuals have been used in qualitative research. Focus groups ideally consist of small groups and are organized in a way that the group setting promotes thoughtful discussion of the experience being explored in the study.

Interviews can have any degree of structure, ranging from specific questions that are asked consistently of each participant to an interview that is very open-ended and non-structured. The amount of depth and richness of the data tend to vary inversely with the degree of structure imposed on data collection: More structure generally leads to less richness and depth, while less structure facilitates greater depth. This may seem counterintuitive at first. Consider asking a friend about some recent travel. If the conversation progresses according to a series of structured questions – where did you go, how long were you there, how did you travel, what did you do, did you have a good time – the answers likely are limited to the scope of those questions and there will be less opportunity for the person you are talking with to bring up what they thought was most important about the travel. In a non-structured interview, there is more opportunity to learn what is most important to the person describing the experience, which is ideal in a qualitative study. The researcher helps to guide the interview by thinking about the research question of interest, for example, what is it like for people to live with OSA? After starting with a broad opening question, the researcher allows the participant to talk, presenting their experience in whatever way is comfortable so the conversation flows naturally for the participant. This might be as broad as “I understand you have been diagnosed with OSA. What has that been like for you?” This allows the participant to reveal things that are of greatest concern or interest regarding the experience without the researcher providing too much direction or imposing restraint on the conversation. The researcher focuses on listening, delicately guiding the conversation to ensure that relevant aspects are covered and participants provide a thorough account of their experiences, but without abruptly redirecting the interview or otherwise imposing constraints on the conversation. The researcher will have some specific questions that they want to address with each participant, such as symptoms, timeline of events, treatments received, and family history as just a few possibilities. Questions about these aspects of the experience can be incorporated into the interview at appropriate times if this information does not arise naturally during the interview.

187The emphasis on listening and facilitating the participants’ elaboration about their experiences can be challenging for nurses who are accustomed to collecting information from patients or clients relevant to a health situation. Nurses are very skilled at eliciting specific information and then formulating conclusions and determining the actions that are appropriate. It is easy for the novice qualitative researcher to interject suggestions, make decisions, or prematurely assume understanding of the participant’s situations. In an interview for qualitative research, however, the investigator must learn to listen very attentively and to tolerate some gaps and silence in the interview while the participant is reflecting and forming next statements. The researcher needs to be able to track the conversation and return to significant items in the conversation when appropriate, and gently redirect when appropriate. While participants need to be allowed to present their experiences as they perceived them, introducing aspects and ideas they found to be important, the researcher needs to be careful that participants do not stray completely off topic. If the interview turns into a rambling conversation the participant can become fatigued and the quality of the interview will be compromised. This also is a long time to listen with great focus, thus the researcher may miss important points as attention fades. People also have busy lives and typically cannot dedicate unlimited time to an interview. The typical in-depth interview lasts about 90 minutes to 2 hours, and the researcher does need to make sure that the interview is sufficiently on track so that the desired information is obtained within a reasonable time frame.

An interesting feature of qualitative research is that some of the data in the study actually come from (or are generated by) the researcher. Data usually are thought of as information that is collected from the people who are being studied, in other words, the subjects of the study. In qualitative studies, however, it is important that the researcher generate some of the data. Such data include notes about the researcher’s actions, thought processes, and decisions made throughout the course of the investigation. The researcher also will prepare documentation that is helpful to understanding and, later, analyzing the interview data. Notes about the setting or context for an interview as well as observations made during the process of data collection, such as notes about a participant’s behaviors or nonverbal communication, are referred to as field notes. These notes provide insights that are valuable in the analysis of data as they facilitate understanding the situation being studied (Rodgers & Cowles, 1993).

Evaluating the quality of data collection procedures in a qualitative study involves looking at a number of factors related to the subjects as well as the researcher. The researcher must have gathered data from participants who have had the experience of being studied, who are able to articulate their experiences, who feel comfortable and unconstrained in sharing their experience, and who have adequate opportunity to share the experiences of interest. Accomplishing this places a considerable burden on the researcher who must develop effective rapport with participants, to ensure confidentiality necessary to protect their identity when discussing matters that can be sensitive to the individual, and to use effective interviewing techniques to obtain comprehensive and clear data that can be analyzed appropriately to answer the research question. In reading a qualitative study, it is important to consider the situation in which the data collection took place; for example, provisions for privacy during the interview; the amount of time allowed for an interview; efforts made by the researcher to establish rapport; other factors such as gender, culture, ethnicity, language, or age that might affect the researcher–participant relationship; means to ensure accuracy of the data collected such as by audio-recording of interviews; and any other information the researcher provides about strategies used to enhance the quality of the data collected. The researcher also should provide an account of notes that were taken during the data collection session and how these were used to supplement the data collection process and enhance the quality of the data.

188Data Analysis in Qualitative Research

Data analysis can be an intimidating process in any study. In qualitative research the volume of information, along with the lack of any prescribed structure for organizing and analyzing it, can be overwhelming, particularly for investigators new to the process. It is also the case that this process can be the most enjoyable part of the research. This is the part of the research process where the inquisitive mind, the puzzle-solver, the curious and the creative aspects of the nurse are allowed to grow and thrive.

There are many approaches to the analysis of qualitative data with some specific guidelines that are unique to each tradition of research. Grounded theory, for example, involves a process of analysis that leads toward the identification of a core variable, a central concept that describes the experience being studied, and then categories of information or themes that contribute to that core of the experience. Phenomenology involves a search for significant statements and meaning in the data, and narrative research focuses on stories. In spite of these variations, however, all qualitative procedures have in common a similar process of reducing the data to manageable units and then constructing a description of the experience being studied by putting back together the pieces of the data into a coherent whole.

Some common steps in the process of data analysis are presented in Exhibit 10.1. It is important to recognize that not only is the process different for each methodology, but the process also is not linear. There are, however, some aspects of data analysis that are fairly common across methods. When interviews are done in a study, one of the first steps is preparing the data for analysis. This involves getting verbatim transcripts of the interviews and checking those for accuracy. The process of analysis then begins with a stage of general data reduction. Typically, the researcher 189will read through the data (assume an interview transcript here for this purpose) identifying statements or parts of statements that carry a unique idea, and will label or code those statements using some term that captures the essence of that statement. This process of coding, carried out with all of the data collected in the study (including data generated by the researcher), reduces the large volume of data in the transcripts to smaller segments that then become the focus of further analysis. Working with these codes, the researcher begins to organize the codes into a meaningful structure with common ideas grouped together. The researcher is looking for patterns or recurrent ideas in the data (sometimes called themes) and the data are organized and reorganized into categories until clear patterns or themes can be identified. This process of organizing and categorizing is continued until the researcher can identify the particular themes or categories that account for and reflect the data that have been gathered without leaving any gaps in the resulting cluster of categories (Knafl & Webster, 1988). It is not necessary to account for every element of data in identifying themes or patterns. There will always be more questions, new avenues to explore, ideas of where research is needed, and so on. There should not, however, be major pieces of data that are ignored or left out of this categorizing process or major gaps in the themes that are identified.

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