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

Transcription

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

2 Ontology and paradigm What is qualitative method When to use it How to use it Data collection Data analysis Mixed Method Instrument development Thrustworthiness Reviewing qualitative methodology

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4 Gain insights through discovering meanings Comprehension of the whole, not causalities Depth, richness and complexity of a phenomena Is dependent of the context Researcher is part of an iterative process, but should not influence the informant

5 Glaser & Strauss 1965 studied awareness of dying Practice at the time: people should not be told they were dying The health care protected the patient from knowing This approach created loneliness and isolation Kübler-Ross studies 1969 "On Death and Dying five stages of grief: denial, anger, bargaining, depression and acceptance Hospice enviroment for end-of life care changed

6 Quantitative method: facts Describe, quantify e.g percentage of men/women, length of in hospital stay, symptoms Find correlations and causalities Uni- och multivariate analysis Generalisability random samling Qualitative method: understanding Partly unknown phenomena Complex phenomena

7 Qualitative Quantitative Paradigm Naturalistic/hermenutic Positivistic Ontology Realism Constructivism Epistemiology Understand Explain Design Open, can be altered Fixed, predetermined Data Text, narratives, observations Numbers Sample Small sample Larger sample Role of the researcher Closer to the contex, interaction with study subjects Neutral Generalisability Transferability Generalisability Quality Rigour Trustworthiness: Confirmability Credibility Transferability Dependability Validity Reliability

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

9 Theory Deductive Inductive Empirics the reality

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12 (ROBERT FROST ) Two roads diverged in a wood, and I- I took the one less traveled by, And that has made all the difference 12

13 When the goal is to explore or understand the meaning of a phenomenon Research areas: Lived experiences, perceptions, thoughts, expectations, motives and attitudes

14 How do patients' and family members' perceive disclosure of healthcare incidents? Can patient and family interviews derive principles of effective disclosure? Iedema R et al. Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study. BMJ. 2011;343:d4423.

15 What matters to older people with assisted living needs? A phenomenological analysis of the use and non-use of telehealth and telecare. Greenhalgh T et al. Soc Sci Med. 2013;93:86-94

16 Identify potential risks and benefits associated with blogging and determine if social media can play a role in supporting patients with multi-drug resistant tuberculosis Horter S et al Plos One 2014;9;e108591

17 Generate hypothesis Confirm and deepen quantitative findings Produce in-depth knowledge before creating an instrument or intervention, a definition, theory or model Develop PROM - instruments developed to mirror the voice of patients Alternative end-point Quality registries As part of a mixed method Evaluate complex interventions Systematic review and meta-analysis of qualitative studies

18 How do women who are being abused by their partners want their health care providers to react to the disclosure of this abuse? Feder GS et al. Women exposed to intimate partner violence: expectations and experiences when they encounter health care professionals: a meta-analysis of qualitative studies. Arch Intern Med 2006;166(1):22-37

19 Early infant male circumcision (EIMC) is simpler, safer and more cost-effective than adult circumcision. In sub-saharan Africa, there are concerns about acceptability of EIMC which could affect uptake. In 2009 a quantitative survey of 2,746 rural Zimbabweans (aged 18-44) indicated that 60% of women and 58% of men would be willing to have their newborn son circumcised. Willingness was associated with knowledge of HIV and male circumcision. This qualitative study was conducted to better understand this issue. Mavhu W et al. Acceptability of Early Infant Male Circumcision as an HIV Prevention Intervention in Zimbabwe: A Qualitative Perspective. Plos One 2012;7(2):e Epub 2012 Feb 27

20 Lewin S et al. BMJ 2009;339:b3496

21 Phase 1 Item development from a content analysis of the literature and qualitative interviews Phase 2 Content validity assessment and pilot testing Phase 3 Field testing, factor analysis, and reliability estimation

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25 Discipline Research method Area of inquiry Antropology Ethnography Holistic meaning of a culture, a cultures shared rules, semantic rules Sociology Grounded theory Social structural processes in a social setting Social interactions Psychology/ Philiosophy Phenomenology Experiences of individuals lifeworld

26 Stemming from a theoretical or epistemeological position Flexible and independent of theory Grounded theory Ethnography Phenomenology Content analys Thematic analysis

27 Conventional Inductive Manifest or latent Data guide development of categories Directed Deductive Theory guide development of categories Summative Identifying and summing of key-words Hsieh H-F. & Shannon S.E. Qualitative health research 2005;15; , Graneheim U & Lundman B. Nurse Education Today 2004; 24:

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33 (1) Death as a natural part of life (38%) (2) Death as a relief from symptoms and disability (13%) (3) Death as fearful (22%) (4) Arrangements for time after death (7%) (5) A wish for an extended life (20%) Strömberg A & Jaarsma T. Eur J Heart Fail. 2008

34 Inductively describe emotional reactions of terminally ill patients who are receiving hospice care Deductive validation of Kubler-Ross five stage of grief (denial, anger, bargaining, depression and acceptance) The summative occurence of the terms die, death and dying in comparison to euphemisms like passing, going to a better place etc.

35 Thematic analysis is the most common form of analysis in qualitative research Themes are patterns across data sets that are important to the description of a phenomenon and are associated to a specific research question Thematic analysis is performed in six phases : familiarization with data generating initial codes searching for themes among codes reviewing themes defining and naming themes producing the final report

36 Developed in sociology, symbolic interactionism Glaser & Strauss 1967 A method to develop new models and theories Data collection and data analysis is done in parallel constant comparison Saturation Literature review after development of a new theory Glaser, B. (1992). Basics of grounded theory analysis. Mill Valley, CA: Sociology Press

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39 Roots in philosophy- Husserl, early 20 th century Many schools Lived experience of a phenomenon Four steps Bracketing Narrative reading Coding Define essens of the phenomena

40 asks for the very nature of a phenomenon, for that which makes a some thing what it is and without it could not be what it is

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44 Flexible, evolve as the study progress Some decision has to be made during design Seldom strict protocols and forms Form for sociodemographic data Interview questions/guide Creativity for workable solutions in problematic situations Research questions/aims Literature review? Can be done before or after the analysis Pre-understanding and prejudice

45 N=? Information-rich cases Non-probability sampling Convenience sampling Quota sampling to include underrepresented groups, ensure variation Purposive (judgemental) sampling Most representative or informative participants Theoretical sampling GT - constant comparative method Emerging findings guide sampling to ensure representation of important themes saturate categories Network sampling Snowball - referrals from earlier participants

46 Interview Observation Document analysis medical charts, patient diaries

47 External Participation - lowest degree of involvement. Observing situations on television or videotape. Passive Participation - researcher is present but does not interact or participate. Role of a bystander or spectator. Balanced Participation - researcher maintains a balance between being an insider and being an outsider. The researcher observes and participates in some activities, but does not participate fully in all activities. Active Participation - researcher generally does what others do. While beginning with observation to learn the rules, as they are learned the researcher becomes actively engaged in the activities of the setting. Total Participation - researcher is a natural participant. Highest level of involvement and usually comes about when the researcher studies something in which he or she is already a natural participant.

48 Level of control Semistructured open interview with six to eight questions/areas Structured, standardised with exact, predetermined questions asked in the same order Unstructured narrative interview with little interference by the interviewer Structured seminstructured unstructured Polit D & Beck C. Nursing Research. 2012

49 Ask How did you react? Instead of Where you upset? Open questions will give good quotations Open questions begin with Tell me about How did you What did you experience/do/think Can you describe

50 Can you describe your experience of living with breast cancer The diagnosis Time before surgery Hospitalisation after surgery Discharge Out-patient treatment: radiation or chemotherapy Rehabilitation and follow up Ryan F et al. Int J Therapy Rehab 2006;16:309-14

51 Individual interview Focusgroups Telephone interviews Repeted interviews

52 Information to the participant Possible scenario Pilot interview Place for interview Tape recording Gain trust Be involved, but keep distance Debriefing

53 The art of active listening The art of asking the right questions Trigger narratives Structuring & standardisation Fixed questions, guide or one open question Avoid directed, imprecise and general questions Be open and let the informant have the initiative initially, be more guiding and reflecting at the end Follow up questions To clarify, develop, deepen Can you tell me more about Can you explain how you mean Previously you said that... Be nagging at the end...

54 Exploring question: Can you tell me about your experiences having a myocardial infarction Structuring questions: I would not like you to move on to a different topic Follow up questions: Could you say some more about that, What do you mean by. Probing question: You mentioned feeling angry, can you tell me more about that Specifying questions: What did you do then Interpreting question: Do you mean that warm up and closing question

55 Evaluate with participant Ask for a later contact for validation of interviews if planned Offer support/telephone contact Write notes/memos Transcribe interviews verbatim

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58 Begin analysis during the fieldwork; make notes and memos Inventory and organize data Fill in the gaps in the data as soon as possible Protect the data Reaffirm the purpose of inquiry Make decisions about software Schedule intense dedicated time for analysis Clarify and determine initial analysis strategy Be reflective and reflexive Keep an analysis journal

59 Code data Find patterns Label themes Develop category systems Matrix analysis Interpreting findings

60 Meningful units Codes Essence Theory Themes- subthemes Category -subcategory

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

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

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65 Quoting is a process that requires the proper balance between scientific reporting and the taking of artistic license Quotes are used to: support researcher findings illustrate results illuminate experience evoke emotion provoke response

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68 New methodology that evolved the last 25 years Endorse two different perspectives in one study Strengths and challenges Researchers/team need to be skilled at both methods Different types of designs

69 CONVERGENT DESIGN Qualitative datacollection and analysis Compare Interpretation Quantitative datacollection and analysis EXPLANATORY DESIGN Quantitative datacollection and analysis Follow up results Qualitative datacollection and analysis Interpretation EXPLORATORY DESIGN Qualitative datacollection and analysis Develop Quantitative datacollection and analysis Interpretation

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83 Question-answering process may be complex involving several cognitive steps Some processes are consious and some automatic Cognitive interviews reveal information on the process

84 Verbal Probing Techniques

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87 87 Development of instrument Revision/adaptation of instruments Translation of instruments

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89 Literature review questionnaires and patients experiences Patient interviews Item generation Expertpanel nurses, patients, phycians Evaluating items (adding/deleting/changing items) Initial testing of items and answering alternatives via ThinkAloud interviews Rephrasing Data collection for validation

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92 If there were only one thruth, one could not paint hundreds of canvases on the same theme. Pablo Picasso 1966

93 The findings are worth paying attention to (Lincoln & Guba, 1985, p.290). Four issues of trustworthiness: Credibility - confidence in the 'truth' of the findings Transferability - showing that the findings are applicable in other contexts Dependability - showing that the findings are valid, consistent and can be repeated Confirmability - a degree of neutrality or the extent to which the findings of a study are shaped by the respondents and not researcher bias

94 Traditional Criteria for Judging Quantitative Research objectivity

95 Traditional Criteria for Judging Quantitative Research Alternative Criteria for Judging Qualitative Research objectivity mirror 'truth not biased confirmability internal validity methods sound credibility external validity results applicable in other contexts transferability reliability consistent and can be repeated dependability

96 In qualitative method the subjective judgement of the researcher is considered an asset. Subjectivity is essential for the understanding of human experience. Polit, D. F. Beck, C. T. Nursing Research. 8th Ed, Lippincott Williams & Wilkins, Philadelphia, 2008

97 Confirmability is a measure of how well the findings are supported by the data collected. (Lincoln & Guba, 1985) In-depth methodological description to allow results to be scrutinised Data audit of decisions made and procedures described Admission of researcher preunderstanding, beliefs and assumptions Triangulation to prevent investigator bias Testing rival explanations Negative cases Recognition of limitations

98 Credibility is an evaluation of whether or not the research findings represent a credible conceptual interpretation of the data drawn from the participants original data (Lincoln & Guba, 1985) Quality of the research rigour Sampling Data collection Interviews, observation Tape recording, transcripts Established authority of researcher Data analysis - How well categories and themes cover data. No relevant data have been excluded or irrelevant data included. The hermenutic spiral Integrity in the analysis Independent coding consensus discussion

99 The whole is build of the parts To motivate the interpretation of the whole the meaning of the parts need to be interpreted The interpretation of the parts has to be in conjunction with the whole. Context -decontext

100 Triangulation Methods Theory/perspective Analyst Test the inter- and intra-rater reliability of the coding scheme Co-examiner Level of agreement (65-100%) Cohen s kappa Empirical ground Agreement/concordance with reality Check with participants/experts Accordance with previous research

101 Transferability is the degree to which the findings of this inquiry can apply or transfer beyond the project (Lincoln & Guba, 1985) Generalisability Comparison of sample to demographic data Theoretical or purposive sampling Rich descriptions Describe in detail the research context and the assumptions that were central to the research. The person who wishes to "transfer" the results to a different context is then responsible for making the judgment of how sensible the transfer is

102 Dependability is an assessment of the quality of the integrated processes of data collection, data analysis, and theory generation (Lincoln & Guba, 1985) The degree to which data change over time and alterations made in the researcher s decisions during the analysis process. Evaluating inconsistency during data collection and analysis. Peer examination Code-recode Dense description of research method allow the study to be repeated

103 We do not see things as they are, we see things as we are. Talmudic Saying

104 To develop a checklist for explicit and comprehensive reporting of qualitative studies (indepth interviews and focus groups). Comprehensive search in Cochrane, Medline, CINAHL, systematic reviews of qualitative studies, author or reviewer guidelines of major medical journals and reference lists of relevant publications for existing checklists used to assess qualitative studies. Seventy-six items from 22 checklists were condensed into a comprehensive checklist with 32 items into three domains: (i) research team and reflexivity, (ii) study design and (iii) data analysis and reporting.

105 Personal characteristics 1. Interviewer/facilitator Which author/s conducted the interview or focus group? 2. Credentials What were the researcher s credentials? E.g. PhD, MD 3. Occupation What was their occupation at the time of the study? 4. Gender Was the researcher male or female? 5. Experience and training What experience or training did the researcher have? Relationship with participants 6. Relationship established Was a relationship established prior to study commencement? 7. Participant knowledge of the interviewer What did the participants know about the researcher? 8. Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. bias, assumptions, reasons and interests in the research topic

106 Theoretical framework 9. Methodological orientation and theory What methodological orientation was stated to underpin the study? e.g. grounded theory, phenomenology, content analysis Participant selection 10. Sampling How were participants selected? e.g. purposive, convenience, consecutive, snowball 11. Method of approach How were participants approached? e.g. face-to-face, telephone, mail, 12. Sample size How many participants were in the study? 13. Non-participation How many people refused to participate or dropped out? Reasons? Setting 14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace 15. Presence of non-participants Was anyone else present besides the participants and researchers? 16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date

107 Data collection 17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested? 18. Repeat interviews Were repeat interviews carried out? If yes, how many? 19. Audio/visual recording Did the research use audio or visual recording to collect the data? 20. Field notes Were field notes made during and/or after the interview or focus group? 21. Duration What was the duration of the interviews or focus group? 22. Data saturation/redundancy Was data saturation/redundancy discussed? 23. Transcripts returned Were transcripts returned to participants for comment and/or correction

108 Data analysis 24. Number of data coders How many data coders coded the data? 25. Description of the coding tree Description of the coding tree? 26. Derivation of themes Were themes identified in advance or derived from the data? 27. Software What software, if applicable, was used to manage the data? 28. Participant checking Did participants provide feedback on the findings? Reporting 29. Quotations presented Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number 30. Data and findings consistent Was there consistency between the data presented and the findings? 31. Clarity of major themes Were major themes clearly presented in the findings? 32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?

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