Qualitative researchers begin the research process with reviewing the literature and identifying a research problem. Depending on the research problem and type of knowledge that is needed, the qualitative researcher develops objectives or questions and determines which philosophical approach will be used to guide the study (see Chapter 4). The early steps of the qualitative research process, which is similar to the quantitative research process, are explored in Chapters 5 and 6. Other steps in the research process are implemented differently in or are unique to qualitative studies. In this chapter, information about qualitative methodology will be provided so that you can understand the process and envision what the experience will be like if you conduct a qualitative study. Maintaining rigor in the context of flexibility can be difficult. Therefore, we suggest that you seek primary and additional sources of guidance for understanding the philosophical base you plan to use, as well as the process of collecting and analyzing qualitative data. A research mentor, especially a researcher with more experience with the methods you are using, can be invaluable. By sharing their personal experiences with the mentees, research mentors can guide less experienced researchers in application of research principles in qualitative studies (Kostovich, Saban, & Collins, 2010). Qualitative studies are motivated by the desire to know more about a phenomenon, a social process, or a culture from the perspectives of the people who are experiencing the phenomenon, involved in the social process, or living in the culture (Creswell, 2007). The motivation may be that nurses realize that patient teaching is not effective with a specific group. A new project may be planned for low-income teenage mothers, but all those implementing the project are more than 40 years of age and have above average incomes. A hurricane ravages a community, and disaster relief efforts are not well received by the community. Persons with sickle cell anemia are living past age 60 years, and previous studies are focused on younger persons who are being diagnosed with the disease. Any of these situations may indicate the need for understanding the insider’s perspective that could be addressed by a qualitative study. For example, Lesniak (2010) established the need for her phenomenological study by defining the phenomenon of self-injury from the literature, indicating the problem of uncaring treatment, and identifying the nurses who could most benefit from the information: Swanlund (2010) provided the rationale for her exploratory descriptive study by describing the research findings related to medication management in older adults. She noted that other researchers had focused on medication management for a single illness, instead of the more realistic situation of taking medications for multiple chronic illnesses. “Additionally, the research questions for these studies were derived from the healthcare providers’ perspectives. These studies have left many questions unanswered regarding the reasons for nonadherence from the perspective of the older adult” (Swanlund, 2010, p. 23). On the basis of this reasoning, Swanlund asked 27 adults older than 74 years to describe situations that helped or hindered their ability to manage their cardiovascular medications. Both Lesniak (2010) and Swanlund (2010) conducted a review of the literature and referred to the conclusions of their review, which confirmed a lack of evidence about their topics. However, some qualitative researchers defer the literature review until after data collection and analysis to avoid biasing their analysis and interpretation of the data (Walls, Parahoo, & Fleming, 2010). Most often, qualitative researchers review the literature at the beginning of the process to establish the need for the study and to provide guidance for the development of data collection methods. A more thorough review of published research findings and theories may occur during data analysis and interpretation to “place the findings of the study in the context of what is already known about the phenomena” (Speziale & Carpenter, 2007). Theory is an explicit component in some qualitative research designs. The expectation of grounded theory researchers is that qualitative research is inductive in nature and that theory will emerge from the data (Speziale & Carpenter, 2007; Walls et al., 2010). Parse’s (2001) research methodology begins with selecting phenomena to study that are universal human experiences, move through analysis using Parse’s theoretical principles as a guide, and end with evaluating the findings for their contribution to her theory. Researchers who used Parse’s research methodology usually present their findings using language from Parse’s theory. Chen (2010) used Parse’s research method to study the lived experiences of persons with spinal cord injuries. From the stories told by the participants, Chen stated the structure of the experience in one sentence: “The lived experience of moving forward is confronting difficulties, going on and finding self-value and confidence to affirm oneself while co-creating successes amid opportunities and restrictions” (p.1138). Chen further transformed the structure through conceptual integration into the conclusion that “moving forward is transforming the valuing of originating ‘enabling-limiting’ ” (p. 1138). Exploratory qualitative study design may benefit from making explicit the researcher’s theoretical perspective on the research problem. Scott and Wilson (2011) used the ecology theory for their qualitative study of African Americans living in the South in the United States. The ecology theory was consistent with their research objective, “identifying potential social determinants of health among African Americans in a rural community in the Deep South, from the perspectives of African American community members” (p. 3). In Singapore, researchers Cheng, Qin, and Tee (2009) interviewed patients with hematological disorders about their experiences in isolation. They noted that Maslow’s (1987) hierarchy of needs theory and Roy’s Adaptation Theory (1976) guided the development of the interview questions and the data analysis. Qualitative researchers who use frameworks during study development must maintain intellectual honesty to prevent the theoretical perspective from obscuring the perspectives of the participants. Your decision about whether to identify a theoretical perspective should be consistent with the research approach you have chosen. If a theoretical perspective has shaped your views of a research problem, you should acknowledge that influence and indicate explicitly the components of the study guided by the theory. The purpose should clearly identify the goal or aim of the study that has emerged from the research problem and literature review. The purpose of qualitative studies should include the phenomenon of interest, the population, and the setting (see Chapter 5). Ask yourself, “Can I achieve this purpose with a qualitative study?” Study purposes such as testing an intervention and determining the effectiveness of a program are not consistent with qualitative approaches. However, a qualitative researcher could address the participants’ experiences with the intervention or their perceptions about a program. The purpose of qualitative studies will vary slightly depending on the qualitative approach that is being used. For example, note in Table 12-1 that the phenomenological study focused on life-world of the participants and the grounded theory study focused on the processes used to maintain hope. The purposes listed in Table 12-1 are consistent with the study’s identified philosophical approach. TABLE 12-1 Selected Examples of Purpose Statements in Qualitative Studies Hypotheses are not appropriate for qualitative studies because hypotheses specify outcomes of studies and variables that are to be manipulated or measured, actions that are not consistent with the philosophical orientation of qualitative research. Qualitative researchers may identify research objectives or questions to connect the purpose of the study to the plan for data collection and analysis. Because qualitative research is more open-ended and the focus is on the participants’ perspectives, qualitative researchers may not specify research objectives or research questions in order to avoid prematurely narrowing the topic. In their study of the occupational stress of children’s palliative care nurses, McCloskey and Taggart (2010) identified two research objectives: These objectives clearly stated and did not limit what the researcher might find. These are ideal characteristics of objectives for a qualitative study. McCloskey and Taggart (2010) found four themes that described the experiences of the nurses: work demands, relationships, maintaining control, and support and roles. The theme of relationships was seen as particularly challenging because of emotional demands and ethical conflicts. A research question establishes “the perimeters of the project and suggest the methods to be used for data gathering and analysis” (Corbin & Strauss, 2008, p. 19). Research questions may be broadly stated or may be based on a theoretical framework if the researcher has identified a framework. Schumacher (2010) identified Leininger’s (1985) theory of culture care diversity and universality as the conceptual guide for her ethnographic study with persons in rural Dominican Republic. Schumacher identified four comprehensive research questions based on the theory. Questions 2 and 4 are provided as examples: Schumacher (2010) developed research questions that were congruent with Leininger’s theory. When a researcher identifies a conceptual framework or guiding theory for a study, the research questions should be congruent with the theory. Schumacher clearly stated appropriately broad questions that included the study’s sample (rural Dominicans) and desired outcome (plan culturally congruent nursing care). The following three themes were identified, each consistent with Leininger’s theory: “(a) family presence is essential for meaningful care experiences and care practices, (b) respect and attention are central to the meaning of care, and (c) rural Dominicans both value and use generic (folk) and professional care practices” (Schumacher, 2010, p. 97). The goal of sampling for quantitative studies is to obtain data from a subgroup of a population that is statistically representative of the population with the intent of being able to generalize the findings to the population (see Chapter 15). Qualitative researchers seek participants who have experienced the phenomenon of interest (Speziale & Carpenter, 2007) and are thus deemed to be “information-rich cases for in-depth study” (Liamputtong & Ezzy, 2005, p. 46). For ethnographic studies, the participants may also include key informants who are knowledgeable of the culture being studied. The selection of participants is nonrandom and may not be totally specified before the study begins. Depending on the research question and the aims of the study, the researcher may use more than one sampling strategy during the study. For example, a researcher who is studying the experience of reacting to a diagnosis of breast cancer may choose to select only women who have not previously been diagnosed with cancer, have not had a family member die from breast cancer, and have been diagnosed within the last 6 weeks. This approach to sampling is called criterion sampling. Similar logic can be applied to identify participants for a focus group, when it is desirable to have participants who can identify with each other’s experiences. When used for focus groups, this sampling method is called homogeneous group sampling (Liamputtong & Ezzy, 2005). Table 12-2 provides definitions and references for sampling strategies that are frequently used by qualitative researchers. These sampling strategies are not mutually exclusive and may be labeled differently by various researchers. TABLE 12-2 Sampling Strategies used by Qualitative Researchers *Considered by some authors to be subtypes of purposive sampling. The sample for a rigorous qualitative study is not as large as the sample for a rigorous quantitative study. The researcher stops collecting data when enough rich, meaningful data have been obtained to achieve the study aims. For new researchers, this answer to “How big should my sample be?” is totally unsatisfactory. When applying for human subjects’ approval, the researcher will be asked the maximum sample size. Giving a generous range of 12 to 25 can be a way to answer this question but will depend on the study design. Researchers who use focus groups often have larger samples. The actual number depends on when data saturation is achieved. Data saturation is the point when new data begins to repeat what has already been found. Patterns emerge in the data. The researcher has the data needed to answer the research question and remain true to the principles of the study design. Marshall and Rossman (2011) indicate that a better term is theoretical sufficiency, because one can never completely know all there is to know about a topic. Chapter 15 also provides some detailed ideas about sampling methods and sample size in qualitative studies. One of the important differences between quantitative research and qualitative research is the nature of relationships between the researcher and the individuals being studied. The nature of these relationships has an impact on the data collected and their interpretation. In varying degrees, the researcher influences the individuals being studied and, in turn, is influenced by them. The mere presence of the researcher may alter behavior in the setting. The researcher desires to connect at the human level with the participant (Corbin & Strauss, 2008). Although this involvement is considered a source of bias in quantitative research, qualitative researchers consider it to be a natural and necessary element of the research process. Shorter and Stayt (2010, p. 161) noted that “the research findings are thus a product of a co-constructive process between researcher and participant.” The researcher’s personality is a key factor in qualitative research, in which skills in empathy and intuition are cultivated. You will need to become closely involved in the subject’s experience to interpret it. Participants need to feel safe and to be able to trust the researcher prior to sharing their deepest experiences with the researcher. It is necessary for you to be open to the perceptions of the participants rather than attaching your own meaning to the experience. To do this, you need to be aware of personal experiences and potential biases related to the phenomenon being studied. It is helpful to document these experiences and potential biases before and during the study in a reflective journal, to be able to set them aside or bracket them. For example, a researcher who plans to interview women undergoing irradiation for breast cancer would need to acknowledge that his/her own mother died from complications of breast cancer. This awareness and ability to be involved with the participants and yet be able to analyze the data abstractly with intellectual honesty is called reflexivity. Reflexivity consists of the ability to be aware of your biases and past experiences that might influence how you would respond to a participant or interpret the data. This ability is critical in qualitative studies because data emerge from a relationship with the participant and are analyzed in the mind of the researcher, rather than through a statistical program (Wolf, 2012). Because data collection occurs simultaneously with data analysis in qualitative studies, the process is complex. Collecting data is not a mechanical process that can be completely planned before it is initiated. The researcher as a whole person is completely involved—perceiving, reacting, interacting, reflecting, attaching meaning, and recording. For a particular study, the researcher may need to address data collection issues related to relationships between the researcher and the participants, reflect on the meanings obtained from the data, and organize management and reduction of large volumes of data. Qualitative researchers are not limited to a single type of data or collection method during a study. For example, one research team used interviews and focus groups in their study of fall prevention for older people in the community (Dickinson, Machen, Horton, Jain, & Maddex, 2011). Lopez (2009) used data from semi-structured interviews, nonparticipant observation, and informal conversational interviews to describe the processes used to make decisions about the care of nursing home residents who become acutely ill. Qualitative data collection may also be combined in a study with the collection of quantitative data. These mixed-methods studies are described in detail in Chapter 10. In many qualitative studies, the researcher observes social behavior and may participate in social interactions with those being studied. Observation is collecting data through listening, smelling, touching, and seeing, with an emphasis on what is seen. Even when other data collection methods are being used, such as interviews, you want to stay aware of your surroundings and attend to the nonverbal communication that occurs between the participant and others in the immediate surroundings (Marshall & Rossman, 2011). Unstructured observation involves spontaneously observing and recording what one sees. Although unstructured observations give the observer freedom, there is a risk that the observer may lose objectivity or may not remember all of the details of the event. The most complete way to collect observation data is to video-record the situation being studied, but doing so may alter the behavior of those being observed or may not be possible because of confidentiality concerns. If video recording is not possible, then the researcher may take notes during the observation periods. If taking notes is a problem, then the researcher needs to record the observations as soon as possible afterwards. Collecting data through unstructured observation may evolve into more structured observations. The researcher may begin with few predetermined ideas about what will be observed. As the study progresses, the researcher clarifies the situations or areas of focus that are most relevant to the research questions and begins to structure the observation. A researcher observing parent behavior in an ambulatory pediatric care clinic may initially focus on the interaction of parents with their children in the waiting area and in the room with the provider. During data collection, the researcher begins to notice common nurturing behaviors of the parents and, from these observations, develops a checklist to use while observing. In this way, the researcher has structured the observations that might be the focus of future studies. Other researchers may enter the setting with a checklist or tool for documenting observations and revise the tool as needed. The notes made during and immediately following the observations are called field notes (Speziale & Carpenter, 2007). Recording observations can be as simple as using a pad and writing utensil in a public place or as sophisticated as producing an electronic diagram of the locations of nurses by having them wear positioning devices. Observations may be supplemented by taking photographs in the setting or video recording an observation. After the observation, the diagrams of the nurses’ positions, the photographs, or the videos may serve to remind the observer of specific elements of the situation. In addition, the researcher may analyze the video by viewing short segments and making notes about each. By reflecting on the photographs and videos, the researcher may identify details that were not captured in the actual observation. The field notes, notes about the electronic records made during the observation, and the researcher’s memories of and reflections about being in the setting are the data that are analyzed. The researcher, by virtue of being in the setting, becomes a participant to some degree. The balance between participation and observation has been described in four ways. The first is complete participation. The people in the situation may not be aware that the participant is a researcher (Speziale & Carpenter, 2007). In public settings, a researcher can ethically observe people and interactions without obtaining permission (Liamputtong & Ezzy, 2005). In less public settings, the researcher may observe others who learn later that he or she is a researcher. When the researcher’s role is unknown to the study participants, they need to have consented to incomplete disclosure before the study is conducted. After the study, they must be debriefed regarding the undisclosed aspects of the study (see Chapter 9). The participants have the option as to whether the data the researcher collected about them is included or not in the study. When the researcher is in the participant as observer role, participants are aware of the dual roles of the researcher from the beginning of the study. Full engagement in the situation may interfere with the researcher’s ability to note important details and move within the setting to follow an evolving situation. In these situations, the role of observer as participant may be more appropriate. As the term indicates, the researcher’s observer role takes priority and is the focus of the data collection. Complete observation occurs when the researcher remains passive and has no direct social interaction in the situation. When the researcher is observing for the purposes of data collection, multiple types of information should be noted. The observer may gather data on the physical setting, the people in the setting, and their activities and interactions. Activities and interactions can be described in terms of their frequency, duration, precipitating factors, and organization. Hall, Pedersen, and Fairley (2010) observed the activities and interactions of nurses during their work on medical and surgical units in three hospitals. The data from 480 hours of observations were analyzed to produce a framework to describe interruptions by source, type, cause, the activity that was interrupted, and the outcomes of the interruptions. In addition to interviewing nurses in a burn intensive care unit, Zengerle-Levy (2006) observed them for 134 hours as they cared for pediatric patients. Through observation, the researcher was able to “uncover common practices that were not articulated” about how they cared for children in the unit in which parents were absent (p.227). Hall et al. (2010) used observation as the primary source of data. Zengerle-Levy (2006) used observations to supplement the data collected during the interview. In both cases, the researchers clearly described the purpose of the observations and details such as total time spent and types of activities observed. This information indicates that observations were effectively used and the study was rigorous. Lauzon Clabo (2008) studied pain assessment on two postoperative units in a teaching hospital. During the first phase of the study, her primary method of data collection was observation. Note the emphasis placed on gaining access to the setting. Lauzon Clabo (2008) followed the initial phase of data collection with observations of individual nurses on the day shift. Each of these observations was followed by an interview with the nurse. The final phase of the study was a focus group on each unit, during which Lauzon Clabo (2008) presented a rough draft of the findings for that unit. On Unit A, the nurses had similar expectations for level and type of pain for specific surgical procedures. They found caring for patients whose pain did not follow the usual trajectory to be challenging because of the need to contact the physician frequently and the desire to keep the physician happy. On Unit B, the nurses focused on the patient’s description of his or her pain and supplemented it with objective and subjective data, such as the use of pain medications. Lauzon Clabo (2008) concluded that pain assessment was a synthesis of the patient’s narrative, evidence from behaviors and medication usage, and expectations based on experience. This study had rigorous methodology as evidenced by the researcher’s going back to the nurses as individuals (interviews) and as a group (focus group) to supplement and validate the initial findings. This rigor gives the reader of the study confidence to view the results as credible. The clinical implications are that nurses must allow the patient’s narrative to take precedence over behaviors, medication usage, and the nurses’ expectations in the assessment of postoperative pain. Depending on the research question, the qualitative researcher may conduct multiple interviews with each participant or may follow an initial interview with another during which the participant can review the researcher’s description of the first interview. Seidman (2006) recommends that the researcher interview each participant three times for phenomenological studies. The first interview is focused on a life history, the second on details of the phenomenon, and the third on reflection on the experience. Using multiple interviews allows the relationship between the researcher and the participant to develop. Over time, the participant may learn to trust the researcher more and reveal insights about his or her experiences that contribute to the study’s findings. Follow-up interviews may be used to share the results of the ongoing data analysis with participants and ask additional questions for clarification. Multiple interviews may be required to study an ongoing process. For a grounded theory study of women undergoing coronary artery bypass graft surgery, Banner (2010a) interviewed the women preoperatively and at 6 weeks and 6 months after surgery. In addition to determining how many times each participant will be interviewed, the researcher will need to plan the interview location, format, and method of documenting the interview. Interviews might be conducted in a room in a public library, a fast-food restaurant at an off-peak time, an exam room in a clinic, or the participant’s home. The location should be selected as a neutral place that has private areas, is convenient for the participant (Speziale & Carpenter, 2007), and considers the safety of those involved. Accessibility and confidentiality should also be considerations. An exam room may not be a neutral site for a study exploring the patient-provider relationship. During a community-based study, the researcher’s appearance may become associated with a stigmatized topic, such as HIV infection, substance use, or domestic violence. A public place may not protect the participant’s identity and confidentiality. A participant’s home may not be safe for the researcher to come to at certain times of day. A participant’s home, however, can offer a sense of comfort and familiarity for the participant and provide the researcher insight into the participant’s experience. Gharaibeh and Owels (2009) conducted a qualitative study of Jordanian women who stayed in abusive relationships (N = 28). They allowed participants to “choose the place of the interview in order to make them feel comfortable and secure” (p. 379). All participants chose to be interviewed in their homes when the husband or other relatives were not present. The format of the interview can be unstructured, semistructured, or structured. Unstructured interviews are informal and conversational and may be useful during an ethnographical study or the early stages of a study. Most qualitative interviews are semistructured, or organized around a set of open-ended questions. Some experts call these topical or guided interviews (Marshall & Rossman, 2011). The degree of guidance may be as minimal as having one initial abstract question or prompt or as structured as multiple predefined questions to narrow the interview to specific aspects of the phenomenon being studied. In either case, the researcher remains open to how the participant responds and carefully words follow-up questions or prompts to allow the emic view, the participant’s perspective, to emerge. Structured interviews are organized with narrower questions in a specific order. The questions may be asked without follow-up questions, and the researcher responses may be scripted in a structured interview (Marshall & Rossman, 2011). Having this level of structure may decrease the anxiety of less experienced interviewers but may result in findings that reflect the etic, or outsider’s, view. The words spoken and the nonverbal communication during an interview are the data. Some researchers prefer to audio-record or video-record the interview and focus on the interaction and relationship with the participant during the interview (Banner, 2010b). A recording of the interview results in a “transportable, repeatable resource that allows multiple hearings or viewings as well as access to other readers” (Nikander, 2008, p. 229). The participant must be aware that the interview is being electronically recorded, but the less obtrusive the equipment, the more quickly the participant will forget its presence, relax, and speak more freely. Logistically, the researcher needs to plan ahead to have the power cords or batteries needed for the recording device (Banner, 2010b). Using batteries may make the device less obtrusive. A sensitive microphone will allow you to pick up even faint or distorted voices, thereby increasing your ability to make an accurate transcription later. If tapes are being used, ensure that the lengths of the tapes are adequate to record the entire interview with few interruptions to change the tape. More likely, the recording will be made on a digital device that can be saved on a computer for transcription. In some situations, recording devices may not be appropriate or the participant may prefer that the interview not be recorded. During the unrecorded interviews, the researcher may take notes and set aside time immediately following the interview to document the interview with as much detail as possible. Preparing to interview is critical because interviewing is a skill that directly affects the quality of the data produced (Marshall & Rossman, 2011). Researchers must give themselves the opportunity to develop this skill before they start interviewing study participants. A skilled interviewer can elicit higher-quality data than an inexperienced interviewer by allowing for silence or asking a probing follow-up question without alienating the participant. Unskilled interviewers may not know how or when to intervene, when to encourage the participant to continue to elaborate, or when to divert to another subject. The interviewer must know how to handle intrusive questions. For practice, conduct interviews with colleagues with experience in interviewing (Munhall, 2012). These rehearsals will help you identify problems before initiating the study (Banner, 2010b). You may want to conduct one or more trial interviews with individuals who meet the sampling criteria to allow you to try out the proposed questions. Practice sessions and pilot interviews also allow you to determine a realistic time estimate for the interviews. Researchers often underestimate the time needed for an interview. Allow yourself enough time so that you can conduct the interview without feeling rushed. Be sensitive to time-related concerns of the participants, however, and offer the option of stopping if an interview is going longer than expected. Participants may need to be able to catch a bus to get home, pick up children from child care, or stop to take a dose of medication. As the researcher, you have the power to shape the interview agenda. Participants have the power to choose the level of responses they will provide. You might begin the interview with a broad request such as “Describe for me your experience with…” or “Tell me about.…” Ideally, the participant will respond as though she or he is telling a story. You respond nonverbally with a nod or eye contact to convey your interest in what is being said. Try to avoid agreeing or disagreeing with what the participant is saying. Being nonjudgmental allows the participants to share their experiences more freely. When it seems appropriate, encourage your subject to elaborate further on a particular dimension of the topic. Use of nonthreatening but thought-provoking questions is often called probing. Participants may need validation that they are providing the needed information. Some participants may give short answers, so you may have to encourage them to elaborate. When the participant stops talking, ask a follow-up question that reflects back on what you have heard. Interviewer responses should be encouraging and supportive without being leading. Listening more and talking less is a key principle of effective interviews (Seidman, 2006). That includes tolerating silence. If the participant is not talking but seems to be thinking or considering the topic, stay quiet. Silence can be a powerful invitation that allows the participant to show deeper emotions and thoughts. In a phenomenological study of persons hospitalized for depression, Moyle (2002) noted challenges with obtaining rich data due to the flattened emotions and slowed cognition that may result from severe depression. During the study, some of the participants underwent electroconvulsive therapy that led to some memory loss. The participants in Moyle’s study had health professionals readily available because they were hospitalized. In other settings, the researcher needs to prepare to refer the participant if necessary. Emotional expression during an interview may be expected, depending on the topic. When the participant becomes distressed or overcome with emotion, however, you may choose to turn off the recording device and stop the interview completely or for a few minutes. You may be able to continue if the participant is able to become composed. Stay with the individual, offer a tissue, and move closer to the participant. Recognize topics that are more likely to be distressing, and have a plan developed for emergency assistance if needed or a list of mental professionals available if support or a referral is needed. For example, you might schedule interviews in collaboration with the chaplain or psychiatric mental health nurse practitioner to ensure that one of them is available for consultation when you will be interviewing family members whose spouses are receiving hospice care. Recognize that you, the researcher, may also need emotional and psychological support. The researcher may be strongly affected by the stories of the participants. Arrange to have a mentor or trusted friend available to talk with before or after interviews. The researcher may need to rest following an interview, because the experience requires heightened focus for an extended period, which can result in fatigue (Creswell, 2007). Greco, Nail, Kendall, Cartwright, and Messecar (2010), in the report of their grounded theory study on mammography decision making among older women (N = 23), limited the sample to women who were 55 years or older and had at least one relative who had been diagnosed with breast cancer. They clearly described the rationale for the study, the selection of participants, and collection of data in the following excerpt: Greco et al. (2010) used a collaborative process to come to consensus during the data collection and analysis process. In addition, some participants were interviewed a second time to assist in refining the theory. These actions strengthened the data collection and analysis process and improved the credibility of the findings. The researchers produced a theory they called “guarding against cancer” (p. 351). Study limitations included an all-white sample and the use of self-report for mammograms. Implications for practice are that health professionals recommending that a woman obtain a mammogram was a strong motivator. Another was that older women may believe they no longer need to be screened and so may stop obtaining mammograms. Focus groups were designed to obtain the participants’ perceptions in a focused area in a setting that is permissive and nonthreatening. One of the assumptions underlying the use of focus groups is that interactions among people can help them to express and clarify their views in ways that are less likely to occur in a one-on-one interview (Gray, 2009). People in a focus group who are alike in some characteristic may feel safer or less anxious when talking about difficult experiences. Many different communication forms occur in focus groups, including teasing, arguing, joking, anecdotes, and nonverbal clues, such as gesturing, facial expressions, and other body language. Focus groups as a means of data collection serve a variety of purposes in nursing research. Focus groups have been used to understand the experiences of people who are receiving care or may need care. Researchers have used focus groups to explore the fatigue of patients following a stroke (Finn & Stube, 2010) and the social support needs of older African Americans who have survived cancer (Hamilton, Moore, Powe, Agarwai, & Martin, 2010). The use of prescription medications without medical care of Latino immigrants (Coffman, Shobe, & O’Connell, 2008) and the excessive drinking of college students (Dodd, Glassman, Arthur, Webb, & Miller, 2010) have also been studied by means of focus groups. Using focus groups, researchers have explored nurses’ experiences such as the stress of providing palliative care for children (McCloskey & Taggart, 2010) and the strategies used in critical care units to prevent and correct medical errors (Henneman et al., 2010). Focus groups of nurses have also been the data collection method for studies of the barriers school nurses encounter when talking to parents about their children’s weight (Steele et al., 2011) and teamwork as experienced by nurses in the neonatal intensive care units and emergency departments (Simmons & Sherwood, 2010). Instrument development and refinement are frequently based on the data collected during focus groups. An example of instrument development was the study conducted by Anatchkova and Bjorner (2010). They conducted focus groups to identify key elements of role functioning as a part of health. The roles identified were to be used to develop items for research instruments measuring quality of life. An example of instrument refinement was the study conducted by Owen-Smith, Sterk, McCarty, Hankeson-Dyson, and DiClemente (2010). Their sample consisted of persons diagnosed with AIDS who used complementary and alternative medicine (CAM) therapies. During two focus groups, the researchers provided the copy of an existing measure of CAM use and asked each participant to complete the instrument. Following completion of the instrument, the participants were asked to identify the strengths and limitations of the instrument. The third and fourth focus groups were not given the CAM instrument but were asked to describe what CAM meant to them. By combining the data from the focus groups, the researchers developed a revised CAM instrument. They validated their findings by having participants in a fifth focus group complete a computer-based version of the revised instrument and provide feedback. This rigorous process produced a revised instrument that will be appropriate for use with the persons diagnosed with AIDS. The effective use of focus groups requires careful planning. The location needs to be carefully selected to ensure privacy, comfort, and safety. Meeting rooms in public facilities such as schools, libraries, or churches may be appropriate community locations for focus groups, depending on the research question and the study aims. For focus groups with specific populations, the facility used for support services may have a quiet room that is accessible and known to participants. Nurses or other health professionals may participate in focus groups in the healthcare facility but might be more forthcoming in a location away from the facility. For a focus group with Hispanic persons who were infected with HIV, a hospital meeting room was selected. When the research team approached the reception desk in a hospital waiting area to ask the location of the room, the staff person stated the location of the “AIDS focus group” in a loud voice heard by the waiting visitors (Gray, 2009). In this case, the researchers’ schedule for travel to the out-of-town focus group did not allow for previewing the location so they did not have the opportunity to inform the reception staff of the name being used for the focus group meeting. If a focus group is planned for a sensitive topic, indicate on the invitation and any materials the name by which the group will be identified. For example, instead of identifying the group as the “Testicular Cancer Study,” a better name might be the “Men’s Health Study.” Other logistics include the expected length of the meeting, recruiting subjects, and recording the group interaction. Focus groups typically last from 45 minutes to Recruiting appropriate participants for each of the focus groups is critical, because recruitment is the most common source of failure. Each focus group should consist of 4 to 12 participants (Marshall & Rossman, 2011). If there are fewer participants, the discussion tends to be inadequate. In most cases, participants are expected to be unknown to one another. However, for a focus group targeting professional groups such as clinical nurses or nurse educators, such anonymity usually is not possible. You may use purposive sampling to seek out individuals known to have the desired expertise (see Chapter 15). In other cases, you may look for participants through the media, posters, or advertisements. A single contact with an individual who agrees to attend a focus group does not ensure that this person will attend the group session. You will need to make repeated phone calls and remind the candidates by mail. You may need to offer compensation for their time and effort in the form of cash, phone card, gift card, or bus token incentives. Cash payments are, of course, the most effective if the resources are available through funding. Other incentives include refreshments at the focus group meeting, T-shirts, coffee mugs, gift certificates, and coupons. Over-recruiting may be necessary; a good rule is to invite two more potential participants than you need for the group. Recruiting participants with common social and cultural experiences creates more homogeneous groups (Liamputtong & Ezzy, 2005). Selecting participants who are similar to one another in lifestyle or experiences, views, and characteristics is believed to facilitate open discussion and interaction. These characteristics might be age, gender, social class, income level, ethnicity, culture, lifestyle, or health status. For example, for a study of barriers to implementing HIV/AIDS clinical trials in low-income minority communities, focus groups might be organized by race/ethnicity and gender. In heterogeneous groups, communication patterns, roles, relationships, and traditions might interfere with the interactions within the focus group. Be cautious about bringing together participants with considerable variation in social standing, education, or authority, because some group members may hesitate to participate fully, whereas others may discount the input of those with perceived lower standing. Establish a setting for your focus group that is relaxed. There should be space for participants to sit comfortably in a circle or U shape and maintain eye contact with one another. Ensure that the acoustics of the room will allow you to obtain a quality audio-recording of the sessions. As with the one-on-one interview discussed earlier, place your audio or video recorders unobtrusively. Use a highly sensitive microphone. Hiring a court reporter to do a real-time transcription may have advantages over recording the interaction for transcription later (Scott et al., 2009). Inaudible voices on the recording or overlapping voices can pose challenges to later transcription. The facilitator is critical to the success of a focus group. Select a facilitator when possible who reflects the age, gender, and race/ethnicity of the group. The researcher may be the facilitator of the group or may train another person for the role. Training of the facilitator should be thorough and allow time for practice (Gray, 2009). The facilitator, sometime called the moderator, needs to deeply understand the aims of the focus groups and to communicate these aims to the participants before the group session. Instruct participants that all points of view are valid and helpful and that speakers should not be asked to defend their positions. Make clear to the group that the facilitator’s role is to moderate the discussion, not to contribute. In addition to the moderator, you may want to have an observer or assistant moderator who takes notes, especially of facial expressions or interactions not captured by the recording (Liamputtong & Ezzy, 2005). Making notes on the dynamics of the group is also useful. Note how group members interact with one another. Taylor and Burch (2011) conducted focus groups to evaluate an enhanced recovery protocol (ERP) that was developed for patients undergoing colorectal surgery. The following excerpt gives further details:
Qualitative Research Methodology
http://evolve.elsevier.com/Grove/practice/
Clinical Context and Research Problems
Literature Review for Qualitative Studies
Theoretical Frameworks
Purposes
Qualitative Approach
Purpose Statement
Phenomenological research
“[E]xplore patients’ lifeworld and way of managing life with advanced PD [Parkinson’s disease] prior to DBS [deep brain stimulation] and to illuminate what they expect from life following DBS” (Haahr, Kirkevold, Hall, & Ostergaard, 2010, p. 410).
Grounded theory research
“[D]escribe the processes that patients in palliative home care use to maintain hope” (Ollson, Ostlund, Strang, Grassman, & Friedrichsen, 2010, p. 607).
Ethnographic research
“[U]nderstand the culture care value and beliefs of women during addiction and recovery” (Lange, 2007, p. 74).
Exploratory qualitative research
“[D]etermine the situations or variables that influence successful cardiovascular medication management, as perceived by community-dwelling adults over age 74” (Swanlund, 2010, p. 23).
Historical research
“[C]harts the international travels of four especially mobile nurses… tells these nurses’ stories and analyzes their ideologies of development and progress” (Irwin, 2011, p. 78).
Research Objectives or Questions
Obtaining Research Participants
Sampling
Definition
Convenience sampling
Inviting participants from a location or group because of ease and efficiency.
Snowball sampling
Researcher asks participants to refer others who have had similar experiences to participate in the study; also called chain sampling or network sampling.
Historical sampling
Exhaustive search for all relevant, surviving primary and secondary sources about an event or phenomenon that occurred in the past (Lundy, 2012).
Purposive sampling
Recruitment of participants as sources of data that can provide and expand upon the data needed to achieve the study aims.
Theoretical sampling*
Recruitment of participants who are considered to be best sources of data related to the study (Wuest, 2012); additional participants may be recruited to validate or expand upon emerging concepts; associated with grounded theory approaches.
Criterion sampling*
Recruitment of participants who do or do not have certain characteristics deemed to affect the phenomena being studied (Liamputtong & Ezzy, 2005).
Maximum variation sampling*
Recruitment of participants who represent potentially different experiences related to the domain of interest (Seidman, 2006).
Critical case sampling*
Recruitment of participants whose experiences with the research topic are expected to be very different.
Deviant case sampling*
Recruitment of participants who may be outliers or represent extreme cases of the domain of interest.
Researcher-Participant Relationships
Data Collection Methods
Observations
Example Study Using Observation
Interviews
Learning to Interview
Conducting an Effective Interview
Problems during Interviews
Example Study Using Interviews
Focus Groups
hours. Liamputtong and Ezzy (2005) indicate that a group might go as long as 3 hours but that participants will begin to tire before 2 hours have passed. Be clear on the recruitment materials about the expected duration of the focus group. Allow for the time it will take to complete consent and demographic forms in determining the length of the data collection process. Provide a reasonable estimate of the time needed, recognizing that whether people attend may be affected by how long the group is expected to last.
Example Study Using Focus Groups
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Qualitative Research Methodology
