Qualitative Research in Healthcare

It is acknowledged in health care that qualitative research offers an important means of gaining insight and understanding of the health and healthcare problems, issues, and processes. It is rooted in the understanding, from the viewpoint of understanding involved, how individual and groups interpret, experience, and make sense of social phenomena (Pop et al, 2002).

Qualitative research deemed appropriate for this research allowing the development of theory whilst taking into account of the local conditions (Crabtree and Miller, 1999). Throughout this study, it was the aim to explore amateur rugby football player’s experiences and perceptions of adhering to a sport injury rehabilitation program.

The attempt to gain insight into people is subjective experiences and the reason of their actions is a fundamental aspect of qualitative research (Polgar and Thomas, 2000), therefore this is the main reason why a qualitative method was used.

The main point of this investigation was interpreting the views of amateur rugby football players. Denscombe (2003) states that qualitative data whether word images are the product of the process of interpretation. The data only becomes data when they are used as such. The data does not already exist there. Therefore, by the researcher adopting a qualitative method it allowed the production and interpretation of the relevant information (Denscomb, 2003). The major purpose of qualitative approach is to operate a hypothesis for further investigation, rather than to test them (Krefting, 1991). This is the reason why the researcher chose a qualitative method over the quantitative method.

Quantitative and qualitative methods are often seen as sitting at opposite ends of the spectrum. However, each has its own strengths and weaknesses and should be used as appropriate in order to best answer a research question. Therefore gaining an understanding of strengths and weaknesses of both approaches is crucial to a researcher prior to embarking upon a research project.

Strengths of Qualitative Research

Qualitative methods are useful when the issues of interests do not seem amenable to quantification (Skyes et al. 1992). Skyes et al. (1992) argued that qualitative research methods will provide an indication of the range of health needs in the area, the relative importance individuals attached to them and ideas about how they can be met. They further state that qualitative research can provide an opportunity for people to express views about services currently available and contribute ideas on the kind of services they would like. As qualitative research is responsive to individual situations, qualitative research can help local people to feel actively involved in the purchasing process rather than the passive providers of the information (Skyes et al., 1992). They further stated that the health need and priorities of less accessible groups in an area or of minority groups may also be most effectively tackled through qualitative methods.

Weaknesses of Qualitative Methods

One disadvantage is, of course, that it is a much younger research tradition than the quantitative one, at least within the ¬eld of health and medicine. Therefore it is not as tested as quantitative methods. It is sometimes regarded as very time-consuming, which is another disadvantage. In qualitative research methods the interviewer may ignore important nonverbal communication or may accept comments at their face value, presenting narrative rather than interpretative analytical reporting (Dodds et al. 1996). Britten et al. (1995) argued that qualitative methods cannot be used for statistical relationships between variables.

Transtheoritical Model (Stages of change)

The transtheoretical (TTM) model has been effectively used as a means of understanding a broad range of health behaviour, including exercise compliance and pain management. This model was developed to assess the processes that individuals go through en route to a behaviour change (Clement, 2008). The original central constructs of this model were the stages of change and the processes of change. The processes of change are thought to be the techniques and strategies used by individuals as they move through the aforementioned stages. These processes can be categorized into experiential and behavioural processes. Experiential processes focus on the individual’s awareness and the feelings experienced while embarking on the behaviour change. Behavioural processes, however, refer to the overt activities that an individual will engage in during the course of behaviour modification.

Self-efficacy is an additional construct that has been incorporated into the TTM. Self-efficacy refers to the confidence an individual has in his/her ability to perform a behaviour. The final construct of the TTM, decisional balance, is derived from the Decision Making Model. This construct is thought to assess the perceived benefits versus the costs of embarking on a new behaviour.

Clement (2008) stated that the stages of change are thought to reflect the varying degrees of readiness experienced by individuals. Marcus and Simkin (1994) argued that processes of change are cognitive or behavioural actions that people employ to modify their perceptions or their environments (or both) as a way of adapt their behaviour. Prochaska and DiClemente (1983) argued that the transtheoretical model comprises of five distinct phases: precontemplation (no intent of making any modifications), contemplation (thinking making some changes), preparation (making little modifications), action (enthusiastically participating within the new behaviour), and maintenance (continuing the new behaviour over an extended period).

Clement (2008) on the basis of his study findings, believed that the transtheoretical model could primarily be used by sports physiotherapist to get an indication of which players are ready for rehabilitation. Then suitable interventions could be used and appropriate referrals made. Interventions that could be used include cognitive strategies such as increasing players’ knowledge about their injury and rehabilitation protocols and increasing players’ awareness of the risks of not adhering to their rehabilitation programs.

Udry, Shelbourne, and Gray (2003) believed decisional balance or person’s insight of the benefits and costs linked with engaging in behaviour. Previous research has suggested that individuals are typically not ready to make vital health-related modifications when they notice the cost as compensating the benefits (Prochaska and Marcus, 1994). Ideally, sports medicine professionals would expect that injured players would both adhere to and comply with their rehabilitation programs since the primary function of rehabilitation is to return the body to its pre-injury level of functioning. However, despite the relative importance of rehabilitation, these professionals have found themselves questioning the commitment of players to their rehabilitation programs. For whatever reason, some players thoroughly engross themselves in rehabilitation while others have a much more listless approach. Furthermore, players have been found to drop out or fail to properly adhere to or comply with even the best conceived rehabilitation programs. Thus, it may be worthwhile to ascertain what could be done before rehabilitation to determine an individual’s readiness for this stage of the injury recovery process to enhance the rehabilitation experience and thereby positively affect adherence and compliance rates.

Precedence for pre rehabilitation assessment has not been set within the context of injury rehabilitation. Such an assessment has been incorporated into investigating how people adapt to new behaviours in other settings, however, Within these studies, the Transtheoretical Model (TTM) revealed that individuals who were advanced in their stages of change exhibited increased self efficacy noticed more benefits than costs and used more behavioural as opposed to experiential processes of change thereby indicated their readiness to embark on a new behaviour. This assessment, using the TTM, could possibly be used to help sports therapist get a better understanding of injured players’ readiness to embark on a new behaviour, that is, injury rehabilitation.

It must be stated that the researcher firmly believes that commencing a rehabilitation protocol can be likened to adapting a new behaviour. While some players may have previously attended and successfully completed rehabilitation, a new behaviour in the current context refers injured players now having to participate in activities (ie, rehabilitation) that are not a part of daily living. These newly injured players can no longer participate in games or training sessions or even travel with the team. Instead, these players now have to schedule treatment and attend rehabilitation sessions. Wong affirmed this assumption by stating that players who are about to commence rehabilitation most often experience a change in their “pre-injury daily routine·

Study Approach

The author of this study reviewed all the available qualitative approaches for this study. A grounded theory approach was not suitable for this study since this approach as a method of qualitative research is a form of a field research (Streubert, Speziale and carpenter, 1999). The aim of the field research is to investigate in an attitudes, beliefs, behaviours and practices of groups or individuals as they function in actual life (Polit and Hungler, 1991). Due to the time restraints of this project, a grounded theory approach was deemed unsuitable. An ethnography approach involves the researcher actively becoming part of the participant’s world (Morse and Field, 1998) therefore the author found this inappropriate for the study.

The researcher concluded that a phenomenological approach using semi-structured interviews would be an effective methodology to answer the research question as the study was based on aspects of personal opinion. Phenomenology has been previously used as a research methodology in health related fields, which will make this study more comparable to other studies in this research area due to the similar designs.

Ethical considerations

Ethical issues are the important part of any research project involving human beings. Most of the issues that give rise to ethical concern in the healthcare fall under one or more of the following headings: ‘informed consent’, ‘privacy and congeniality’, ‘anonymity’, ‘deception’, ‘risk and harm’ and ‘exploitation’ (Sim and Wright, 2000). This study aimed to address all of these areas by taking several measures. An information sheet and a consent form were provided to the participants and asked to sign the consent form

Participants were provided with an information sheet and asked to sign a consent form prior to participation in the research. Confidentially and anonymity was maintained for all the participants involved. All information linking participants to the research project were stored securely and destroyed upon completion of the project. All possible steps were taken by the researcher to reduce the risk of harm and exploitation to participants.

Potential participants were informed that all participants in the research were voluntary and the right to withdraw would continue until the commencement of data analysis.

Ethical permission was granted from the School Of Health and Social Care Ethics Committee, University of Teesside (Appendix 1), prior to commencement of the study. For participants information sheet and consent form see appendix 1.

Informed, written consent to initial participation in the study is necessary and gained before commencing the project and prior to each interview (Kvale, 1996). To ensure participants are fully informed prior to consent being given, any questions raised need to be answered by the researcher. The interviewees were assured of anonymity and confidentiality.

The participants consented to the interviews being recorded, translated and transcribed, before being analysed. Both the recording and transcription were kept locked during the project and destroyed afterwards to maintain anonymity and confidentiality. Prior to analysis the participants were allowed to read the transcript and may clarify meanings of statements, edit the transcripts or completely remove statements so that the transcription is true and accurate and the participant is not misquoted (Rubin and Rubin, 1995). All participants names were changed to pseudonyms.

Burns (2000) highlights that if any determent is threatened or reward offered for non-participation or participation, then the consent given is not voluntary. In this study these factors are made explicit within the consent forms contained in appendix 1.

Denscombe (2003) highlights that the data collected is and should be treated as a genuine reflection of the participant’s thoughts and feelings. The opportunity for participants to withdraw any comments made in the interviews will be given as is stated clearly in the consent forms. The participants were given a copy of the transcripts to proof read and from this, may remove or clarify any statements they made. Rubin & Rubin (1995) advocate this process arguing that, although it may reduce the accuracy or impact of the final project, the protection of the participants should be the primary focus of the researcher.

Participants

A relatively homogeneous purposive sample of nine amateur rugby players (four female and five males) with an age range of 19-29 years took part in this study. Participants’ characteristics are presented in Table 1. This showed, of the nine participants, three had sustained a shoulder injury, two sustained a knee injury, and the remaining four sustained an arm, an ankle, back and a neck injury each.

Table 1 Participants Statistics at the Time of Interview

Pseudonym Age Occupation Injury Sporting level

Chapel 29 PE Teacher Back Amateur

Andrew 20 Van Driver Shoulder Amateur

David 20 Holiday Rep Ankle Amateur

Gordon 22 Teacher Shoulder Amateur

John 23 Sports centre worker Shoulder Amateur

Christine 23 Teacher Knee Amateur

Alison 19 Bar worker Arm Amateur

Diane 28 Rugby Coach Neck Amateur

Marion 28 Part time-Researcher Knee Amateur

Participants were recruited via amateur rugby football clubs through physiotherapists, sports therapists, coach, or managers contacts. Nine participants were selected using a non-probability purposive sampling strategy (Hudson, 2003).

Sample size in qualitative research is necessarily small due, in part, to the complexity of the data. Bowling (2002) supports this and highlights that sufficient size is reached when, upon the judgement of the researcher, concurrent themes and issues are emerging from the participant. Size is therefore flexible, though guided by the time and resources available (Silverman, 2001).

Participants were selected using a non-probability purposive sampling strategy (Hudson, 2003). This was seen as most appropriate for this study as it involves selecting a sample from a population which meets the inclusion criteria of the research study. Purposive sampling involves the researcher using their own judgement to achieve a particular purpose, to satisfy the needs of the study and make the sample theoretically representative (Robson, 2000).

Pilot study

A pilot interview was used to identify any problems with the data collection of the study prior to commencement. It enabled the researcher to establish any topics that had not been initially considered. As it was the researcher’s first attempt at qualitative interviewing, this helped to develop the novice interviewer’s technique and preparation. The findings from this were then used to improve the main interviews.

Piloting the study’s interview allows the researcher to prepare for the main interviews by enabling them to practice in the compilation of information and also in the management, interpretation and examination of the information that is obtained, meeting methodology rigor (Byrne, 2001).

An amateur rugby football player who met the study inclusion criteria was interviewed face-to-face by the researcher. The researcher found from this pilot interview that he was not utilising silence with in the interview to provoke additional responses from participants. Instead, the researcher tried to fill these silences to prevent any awkwardness generated in the interview. Also the researcher was aware that he was asking two-in-one questions which was confusing the participant and not gaining as in-depth answers as would have been obtained from single questions.

The findings were reported by the researcher and used to enhance their interviewing technique for the main interviews. The pilot interview also gave the researcher the chance to develop their conversational style of interviewing, and re-assured the researcher in his confidence to carry out successful in-depth interviewing throughout the study.

Interview

Interview allowed the participants to share their own accounts and opinions with the researcher, describing individual experiences in their own words (Porter, 2000). The semi structured nature of the interview process allows meanings of narrative to be clarified and the opportunity of relevant issues arising to be explored in more depth (Barnes, 1992).

Semi structured interviews were chosen in order to allow the researcher to initially introduce specific themes and questions, but also allowing the participants to disagree, and the researcher to encourage, this exploration of issues. Focus Groups and written narrative would restrict this process by discouraging personal opinions and preventing the exploration of the participants’ feelings throughout the process. Semi structured interviews are generally employed as there is a common belief that the participant’s view and experiences are more possible to be disclosed in a relatively open designed interview situation than in a standardized interview or a questionnaire situation (Flick, 2002).

Rubin and Rubin (1995) also argued that qualitative data could be gathered using a questionnaire but the answer to the questions will be in no depth, there will be no opportunity to explain the answers given or to clarify the meaning. The decision to use semi structured rather than unstructured interviews was made on the basis that this would make comparison and analysis of data easier. This method also allowed themes to emerge and concepts to be developed and expanded upon.

A preliminary schedule of questions was developed based on previous rehabilitation compliance qualitative studies by Pizzari et al (2002). Dr Tania Pizzari is a senior lecturer in La Trobe University School of Physiotherapy, Australia and has extensive teaching experience at postgraduate level. She has extensive research and publication experience, and recognised internationally for her work in field of physiotherapy, sports therapy, sports injury rehabilitation and adherence in physiotherapy. Dr Tania Pizzari research outputs include journal articles, papers and book chapters. Dr Tania Pizzari kindly gave the researcher written permission to use her interview schedule.

Interview Setting

In accordance with Pontin (2000) the researcher attempted to provide a non-threaten, informal setting for interviews to take place. Pontin (2000) reports that this is conducive to the research process and those participants are disposed to be more forthcoming in this setting. All participants asked to select an appropriate date and time for their interview.

Interview Process

At the beginning of the interviews, the questions were more structured to guide the data gathering processes. These are termed the preparatory questions. The structure of the interview followed that proposed by Rubin and Rubin (1995). This involves using three types of questions; main question, probing question and follow-up question.

This style of interviewing was used in order to obtain a rich source of insight into the participants’ knowledge and perceptions of the research topic. It enabled both the interviewer and interviewee to pursue ideas in more detail. It was also anticipated that this style of interview would prevent any bias from the interviewer regarding their own opinions, as the participants themselves would guide the interviews with their answers.

The interviews were conducted face-to-face in a location familiar to the participant to ensure they were comfortable and relaxed throughout the meetings. Prior to the commencement of the interview, participants were given an information sheet explaining the basics of the study and asked to sign a consent form. In addition, the participants were made aware of the intended style of the interview to ensure they were at ease with this. Participants were also informed of their anonymity to the study and their right to withdraw at any time.

The interview lasted approximately 45 minutes; however this did vary due to the individuality of each interview. Each interview was tape recorded and then transcribed as soon as possible to maintain recall.

Field notes were taken during the interview to help during the transcription of the data of emphasise facial expressions, change of voice tone, and context of data or other non-audible cues. As Taylor and Bogden (1984) suggested that triangulation is the gathering of data of different types that helps guard against bias within the research.

The interview required the use of a digital voice recorder to record the interview as that increased the objectivity of the data collection and reduced the risk of the participant’s dispute as to exactly what was said. Videotaping was not used, as it was felt it could be too intrusive (Denscombe, 2003). New batteries were fitted to the digital voice recorder, spares available and all equipment checked for sound and correct functioning prior to the interview.

There are disadvantages of using interviews as data collection methods. Interviewing is very time consuming and it would be difficult to cope the extent of the interview (Denscombe, 1998). If an author wants to keep to the arrangement of the interview, the researcher took time to develop interviewing skills, such as keeping the questions clear and focused before the interview took place.

Data Analysis

Thematic analysis is a method to be used with qualitative data that can be used with most, if not all qualitative methods (Boyatzis, 1998). Thematic analysis is a method for encoding qualitative data, which need an explicit code. Thematic analysis intends to recognise themes within the data (Ezzy, 2001). A theme is a pattern found in the data that at minimum illustrate and categorize the possible observation and at maximum interprets of phenomenon. A theme may be identified at manifest level or at the latent level.

The advantage of thematic analysis is its flexibility.The themes may be initially emerged inductively from the raw data or emerged deductively from theory and prior research. Thematic analysis allows the collection of qualitative data in a manner facilitating communication with other researchers (Boyatzis, 1998).

Thematic analysis is more inductive than content analysis because the groups in which themes will be organized are not determined prior to coding the data (Ezzy, (2001).

These categories are induced from the data. In order to identify themes or concepts from the data, thematic coding was used for data analysis (Ezzy, 2001). The researcher read through each answer many times to recognize important themes, and then summed up the results under thematic headings (Dixon-Woods et al. 2005). Transcripts of interviews underwent a process of thematic analysis as developed by Burnard (1991). The figure 1 (on previous page) illustrate the process.

The aim of this process was to discover topics and issues addressed in the interview and link them together to form a comprehensive system of categories, which illustrates the themes form the data obtained in the interviews. This was a continual process of revising and categorizing the data into themes to ensure that the findings were a truthful and accurate reflection of the data obtained from the participants. This method of analysis was performed manually in order to maintain the richness of the data and to prevent the researcher from being distanced from the study.

With broad knowledge of the relevant literature the researcher constantly compare the data generated from the study to this background research, which in turn prompted question that enhanced their theoretical sensitivity towards this research topic.

Trustworthiness

Terms such as ‘reliability, ‘validity’, and ‘generalization’ commonly used in quantitative research have been replaced by ‘trustworthiness’ (Lincoln and Gaba 1985) in order to encompass a more qualitative approach to the research. The term trustworthiness is used in qualitative research to determine how the researcher has persuaded their audience that the findings from the study are worth paying attention to, and indeed are the ‘truth’ (Lincoln and Gaba 1985).

Credibility in qualitative research relates to the term internal validity. This is more often associated with quantitative research where causal relationships between variables are sought, and it refers to the truth of the study (Krefting, 1991). In qualitative research, the truth of a study relates to how accurately the phenomena being studied are represented. This is reflected in the researcher’s willingness to include contradictory statements rather than to present a one sided argument from the data (Silverman, 2000). Credibility is the term used in qualitative methodology to answer questions about the truth value. As one of the basic assumptions in qualitative methodology is that realities are multiple, credibility refers to the researcher’s ability to capture these realities. Has he or she really understood and described the participants well enough? Would it be possible for other people to recognize themselves, or the context that we describe?

The job of the researcher is to accurately represent the multiple realities revealed by the participants (Koch, 1994). Krefting (1991) suggests that more sensitive information may be offered as a rapport is developed over time. The participants should be more honest in their answers with the assurance of anonymity from the researchers (Rubin and Rubin, 1995).

Credibility will be achieved by ensuring all participants in interviews fulfil the sampling inclusion criteria. This confirms the choice of purposive sampling as the most appropriate method of this study as it will allow rapid identification of participants who can demonstrate relevant experience.

Transferability means the ability to generalise from the findings of the study. Lack of generalisability is one of the criticisms of qualitative enquiry as, due to the uniqueness of each qualitative research situation, it is impossible to replicate results (Holloway and Wheeler, 1996). Shepard et. al. (1993) suggests that within phenomenological research, generalising is not the job of the researcher; instead the reader is required to judge how well the study applies to other situations familiar to them. The job of the researcher is to attempt to describe the particular phenomenon in such a depth as to enable the reader to generalise.

Dependability asks whether the same findings would be achievable if the study were repeated, mirroring the term reliability used in quantitative research. However, it has already been discussed, that inherent in qualitative research is the assumption that multiple realities exist in the complex, ever changing context of an individual’s life. If this is the case it is not relevant for the qualitative research to produce the same results time after time. Lincoln and Gaba (1985) recognise that instead, the qualitative research process should be logical, traceable and clearly documented.

The Conformability refers to the researcher’s ability to be neutral to data. Conformability is also checked by an audit trail, this time meaning that the auditor should be able to ¬nd the derived qualitative results well grounded in data. Conformability requires the findings and interpretations of the study to be explicit within the data (Carpenter, 1987). Finlay (1999) states that fundamental to the process of analysis of a phenomenological study is to stay true to the data, and for themes to arise from the data rather than be imposed on it.