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Articles
An overview of qualitative research
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In this article (part 1 of two), Therése Kairuz, Keith Crump and Anthony O’Brien provide an overview of qualitative practice research in pharmacy
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harmacy practice research has been defined as the rationale, scope, efficiency and effectiveness of pharmacy practice.1 It was described in 1991 as a “new and rapidly expanding area of research”2 which includes a wide diversity of topics such as research into health services, patient populations, service providers and pharmacists. Contributions to the field of pharmacy practice include findings from academics, pharmacy practitioners and pharmacy students, and this article will introduce the reader to aspects of qualitative research, with the aim of stimulating interest in the use of this methodology. Part 1 provides a brief overview of qualitative research for pharmacists and part 2 provides practical advice on the collection of data using focus groups or in-depth interviews and suggestions regarding data analysis. The reader is encouraged to obtain additional information from the references listed in the bibliography. Academics from sociology, anthropology, psychology, economics, history and statistics Therése Kairuz, PhD, MPS, is senior lecturer in pharmacy at the School of Life Sciences, Queensland University of Technology, Brisbane, Australia, Keith Crump, MPharm, MPS, is practice education manager, Procare Health Ltd and mental health pharmacist, Waitemata District Health Board and Anthony O’Brien, MPhil, RN, is from the Centre for Mental Health Research at the University of Auckland. Correspondence to:
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have addressed questions regarding health, pharmacy and drug use.The use of drugs and health services may be determined quantitatively using techniques such as drug utilisation studies or survey methodology, where findings are expressed in numbers or percentages. Quantitative studies can answer questions related to “what” is happening. On the other hand it may be important to explore “why” it is happening. Qualitative research is often exploratory and can be used to generate hypotheses,3 whereas quantitative studies are designed to test them. Health care problems are recognised as complex and should be researched in a manner that can cope with the complexities.4,5 Pharmacy has a direct interface with the public and provides a service to an increasingly wide range of customers. It is inevitable and appropriate that pharmacy practice research has a social or environmental orientation6 and it has been suggested that pharmacy practice researchers need to have an understanding of the wider social care role of the pharmacist. Qualitative methodology allows the researcher to interpret phenomena according to the context and individuals being studied,7 and has been identified as being useful when approaching a research question where there is little established knowledge.8,9 It can be used to preserve the personal qualities of human viewpoints and offers a way of retaining the uniqueness and complexities of individuals. By the early 1990s there were only a few published pharmacy practice studies which depended primarily on qualitative
methods.10 However, qualitative approaches have gained an increased prominence in health services in recent years.11 “Grounded theory” is a term used in reference to the creation of theory based more on observation than on deduction. It is a qualitative method that uses a systematic set of procedures to develop an inductively derived theory about a phenomenon.12 In order to develop a grounded theory, a research question or questions that are broad and flexible, allowing freedom to explore phenomena, are required. The grounded theory approach, or a derivative thereof, facilitates the active engagement of the researcher in close and detailed analysis of the data, thereby stimulating and disciplining how the researcher imagines theories.13 Qualitative research can be systematic, while at the same time stimulating and creative. The grounded theory approach sees the over-riding concern of qualitative research as the generation of theory. The aim of qualitative research is to explore issues from the perspective of respondents and addresses human projects such as the nature and structure of peoples’ attitudes, feelings, ideas, thoughts, frames of reference, motivations and learning processes, among others. It can grasp wholeness, complexities and relationships, and is context-dependent. 4 Qualitative research can thus be used to preserve the personal qualities of human viewpoints. It has been used to explore different aspects of professional practice from the 1980s through the 1990s and into the 2000s.11
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Articles Although qualitative studies may provide valuable information and insight into phenomena, qualitative methodology has been described as a “less reliable” form of research,14 and the issue of rigour must be addressed.
Qualitative research criteria The rigour required when undertaking qualitative research is of paramount importance. There have been a variety of methods that can be used to explore phenomena in a qualitative manner, including interviews,4 focus groups15 and observation.16 Sampling strategies may be purposive,17 representative,18 convenience19 and theoretical. The criteria for establishing methodological quality reflect the nature of the research topic and the theoretical viewpoint of the researcher. Different qualitative research types have their own data-quality procedures and there are differing opinions on the criteria required for qualitative research.Validity and reliability are considered important on the one hand20 and truth value, applicability of findings, neutrality and consistency of data, collectively referred to as “trustworthiness”, on the other.21 Rigour in qualitative research is discussed by Pope and Mays.3 Core criteria associated with qualitative research include ensuring that data are robust and fully explore the research topic.9,22 Data content in qualitative research is guided by the response to questions with the participant, or research subject, serving as the data source. It is important that data selected are not anecdotal and they must be tested for validity. Methods that can be used to ensure robust data include the following:8 n Refutability principle, whereby the researcher seeks to refute his or her initial assumption n Constant comparative method, in which the researcher seeks another case to test his or her initial hypothesis n Comprehensive treatment of data, which includes all data collected within the analysis process n Deviant case analysis, which involves actively seeking out and addressing deviant data
Validity of qualitative research When developing research that broadens collective knowledge it is important to ensure that the method and process have external validity.Agar23 argued that, in qualitative studies, the traditional concepts of reliability and validity do not apply and should be reinterpreted as credibility and accuracy of the way in which material is presented.The authority with which the researcher develops the material is an additional criterion for determining methodological standards in qualitative studies. In a paper exploring rigour in qualitative research, Krefting21 developed a model proposed by Guba (1981) that enables critical appraisal of qualitative research.The model uses four concepts which reinforce trustworthi-
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ness: truth-value, applicability, consistency and neutrality. Krefting develops these themes and explores techniques that can enable the researcher to strengthen the rigour of his or her study. Truth-value Truth-value informs the reader that the researcher has a basis of confidence in the findings he or she has presented. Qualitative research relies on truth-value as an expression of the human experience of the subjects under investigation. The data are therefore a product of the subject and require that the researcher be able to present this experience in a form that is credible. Methods that can strengthen truth-value include adequate field and time sampling, the use of a reflective journal, using several data collection techniques such as focus groups and surveys to provide a convergence of multiple perspectives (described as triangulation), re-examination of the analysed data by research participants (described as member checking) or by peers, and ensuring that the reasoning established by the researcher follows established criteria so that there are no unexplained inconsistencies between data and conclusions (described as structural coherence). Applicability Applicability in research describes whether the research can be used in a context other than its initial context, which is also described as transferability. Although it has been suggested that qualitative research need not be generalised to other settings as its role is often descriptive, Guba (1981) presented a model that suggests data can be transferred if there is a good fit between the two settings.24 In Guba’s model, the ability of qualitative research to fit from one context to another reflects sufficient depth in the data. This also requires that the researcher has developed the topic to include sufficient data over time and to have described and developed the data such that their context can be matched with another situation. Consistency Consistency is described as sustainability of research outcomes if the study were to be conducted with a comparable sample in a similar environment.This implies that data will develop in a similar manner resulting in common outcomes. As qualitative research is focused on observations, the consistency of research findings cannot rely on repeatable experiences. Rather, consistency is reliant on the dependability by which data are collected and the method by which the researcher is informed and develops insight during the research process. The dependability of qualitative research can be strengthened by ensuring full description of data collection and evaluation, the use of methodological triangulation and by using a consistent method of data coding and recoding. Neutrality Neutrality or freedom from bias is pivotal to validity. The paradox of qualita-
tive research is that reducing the barrier between the participants and the researcher may enhance the quality of data. However, this reduced barrier introduces a risk of subjectivity. Qualitative researchers have developed methods of countering the risk posed by subjectivity, including the use of triangulation and the use of a reflective journal.These concepts are considered to enhance the neutrality of research findings, and have been explored and reinforced by researchers using a qualitative paradigm.25 The methods of ensuring credibility were reinforced by Koch, who considered that the researcher brings the perspective of an interpreter and also a historical context that led him or her to the research topic.26 The ability of the researcher to understand his or her evolving perspective is enhanced by the use of a field journal.The journal enables exploration of issues, events and responses during the research process and is a means of credibly documenting this process.
Triangulation Triangulation has been defined as the combining of different types of data, methods or approaches within the same research study. The term derives from navigation, where different bearings are used to achieve a more reliable estimate of the true position.27 If the two approaches are seen as involving the same world view, integrating them is less problematic and the integration of data using both approaches may be seen as valuable. Results are complementary in that they can be added together to triangulate because they are both looking at the same phenomena.28
Ethical stance The ethical stance of the researcher within a qualitative enquiry must be of a high standard and the researcher must be able to develop the material provided by the participants in a trustful, honest and reliable manner. Core ethical issues, including explanation of the research question, informed consent and consideration of any impact the research process may have on participants, need to be clearly outlined. It is important to remember that the social and educational background of the researcher will influence the manner in which he or she regards the research question.
Challenges in qualitative research Qualitative research challenges the idea that research in the human sciences (in which one can include pharmacy practice) should be primarily concerned with the quantitative testing of established theory, but is in turn challenged by the fact that it only allows for the development of concepts and theories.29 It relies on the perceptions of the researcher, as well as field notes (which may go missing), observation (which is influenced by external factors) and memory.The potential for bias as a result of the researcher’s preconception has been identified. Participants may be influenced by external factors at the time of the data collection and therefore findings may not be durable. Findings are context-specific 17 March 2007 The Pharmaceutical Journal (Vol 277) 313
Articles and may not be generalisable.Although triangulation is used to provide different perspectives and a broader range of data it is an argument that developed to overcome the shortcomings of a single methodology. Concerns have also been expressed over combining methods that are underpinned by different philosophical assumptions within the framework of a single study.27 Notwithstanding the above, qualitative research may address issues such as “Why do people think like that?” which ultimately may be more relevant than “How many people think like that?”.10
Summary The reader has been introduced to the concept of qualitative research and its role in pharmacy practice research. Guidelines contributing to conducting quality research have been presented, including the need for an ethical approach to a study. In part 2, “Useful tools for data collection and analysis”, the use of focus groups and face-to-face interviews will be discussed as examples of data collection methods and suggestions on how to analyse data will be presented. References 1. Poston J. An international perspective on research strategy. International Journal of Pharmacy Practice 1991;March:53–5.
2. McElnay J. Getting pharmaceutical care into community practice. Pharmaceutical Journal 1998;261:570. 3. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995;311:42–5. 4. Launsø L. The demands for qualitative research are developing. Journal of Social and Administrative Pharmacy 1991;8:1–6. 5. Faltermaier T. Why public health research needs qualitative approaches. European Journal of Public Health 1997;7:357–63. 6. Gerrett D, Stevenson FA. A dilemma for ‘social’ pharmacy practice research. International Journal of Pharmacy Practice 1995;3:65–7. 7. Bartos R, Lazarsfeld PF. Understanding qualitative research. New York: Advertising Research Council;1992. 8. Silverman D. Doing Qualitative Research. London: Sage Publications; 2000. 9. Hassell K, Hibbert D. The use of focus groups in pharmacy research: process and practicalities. Journal of Social and Administrative Pharmacy 1996;13:169–77. 10. Smith F. Health services research methods in pharmacy: Introduction. International Journal of Pharmacy Practice 1992;5:149–51. 11. Smith F. Research methods in pharmacy practice. London: Pharmaceutical Press; 2002. 12. Glaser BG, Strauss A. The discovery of grounded theory: strategies for qualitative research. Chicago: Aldine; 1967. 13. Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park: Sage; 1990. 14. Gray JAM. Evidence-based healthcare. New York: Churchill Livingstone; 1997. 15. Kritzinger J. Introducing focus groups. BMJ 1995;311:299–302. 16. Mays N, Pope C. Observational methods in health care settings. BMJ 1995;311:182–4.
17. Abraham J, Lewis G. Harmonising and competing for medicines regulation: how healthy are the European Union’s systems of drug approval? Social Science and Medicine 1999;28:1655–7. 18. Abu-Omar SM, Weiss MC, Hassell K. Pharmacists and their customers: a personal or anonymous service? International Journal of Pharmacy Practice 2000;8:135–43. 19. Conrad P. The meaning of medicines; another look at compliance. Social Science Medicine 1985;20: 29–37. 20. Smith F. Health services research methods in pharmacy: Qualitative interviews. International Journal of Pharmacy Practice 1998;6:97–108. 21. Krefting L. Rigor in qualitative research: the assessment of trustworthiness. American Journal of Occupational Therapy 1990;45:214–22. 22. Greenhalgh T, Taylor R. How to read papers that go beyond numbers (qualitative research). BMJ 1997;315:740–3. 23. Agar M. Speaking of ethnography. Beverly Hills: Sage; 1986. 24. Guba, E.G. 1981. Criteria for assessing the trustworthiness of naturalistic inquiries. Educational Communication and Technology Journal 29:75-92. 25. Milton Keynes Primary Care Trust. 10 Questions to help you make sense of qualitative research. Critical Appraisal Skills Programme. Available at: www.phru.nhs.uk/casp/ critical_appraisal_tools.htm (accessed 1 March 2007). 26. Koch T. Establishing rigour in qualitative research: the decision trial. Journal of Advanced Nursing 1994;19:976–86. 27. Smith F. Health research methods in pharmacy. Triangulation. International Journal of Pharmacy Practice 1999;7:60–8. 28. Temple B. 1997. A moveable feast: quantitative and qualitative divides. Journal of Social and Administrative Pharmacy 1997;14:69–75. 29. Atkinson P. Some perils of paradigms. Qualitative Health Research 1995;5:117–24.
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