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Abstract
The aim of qualitative research is to produce empirical evidence with data collected through means such as interviews and observation. Qualitative research encourages diversity in the way of thinking and the methods used. Good studies produce a richness of data to provide new knowledge or address extant problems. However, qualitative research resulting in peer review publications within the Defence Medical Services (DMS) is a rarity. This article aims to help redress this balance by offering direction regarding qualitative research in the DMS with a focus on choosing a theoretical framework, analysing the data and ethical approval. Qualitative researchers need an understanding of the paradigms and theories that underpin methodological frameworks, and this article includes an overview of common theories in phenomenology, ethnography and grounded theory, and their application within the military. It explains qualitative coding: the process used to analyse data and shape the analytical framework. A popular four phase approach with examples from an operational nursing research study is presented. Finally, it tackles the issue of ethical approval for qualitative studies and offers direction regarding the research proposal and participant consent. The few qualitative research studies undertaken in the DMS have offered innovative insights into defence healthcare providing information to inform and change educational programmes and clinical practice. This article provides an extra resource for clinicians to encourage studies that will improve the operational capability of the British Armed Forces. It is anticipated that these guidelines are transferable to research in other Armed Forces and the military Veterans population.
- Qualitative Research
- Audit
- Education & Training (see Medical Education & Training)
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Key messages
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Qualitative research encourages diversity in the way of thinking and methods used. Good studies produce a richness of data to provide new knowledge and insight for addressing extant problems or evidence to challenge traditionally held beliefs.
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Qualitative researchers need an understanding of the paradigms and theories that underpin methodological frameworks. Once understood, they provide a valuable resource.
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Qualitative coding provides a template to systematically analyse qualitative data. Figures, diagrams and colour can be used as a means of providing clarity. The structure ensures that results will be valid and reliable in the empirical evidence produced.
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The few qualitative research studies undertaken in the Defence Medical Services have offered innovative insights into defence healthcare, providing evidence to inform and change educational programmes and clinical practice.
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Research Ethics Committees (RECs) use proposals to judge whether the research is feasible, if it is worth doing, the candidate's ability to complete the study, and if it will produce a worthwhile report and at what level. However, qualitative research is unfolding with new data presenting avenues to be explored. These only emerge after data collection has commenced, and RECs must understand and accommodate this principle.
Introduction
For anyone undertaking qualitative research within the British Armed Forces, and the Defence Medical Services (DMS) in particular, there are a number of excellent guidance books discussing the associated general principles and processes.1–4 Details regarding the overall process for undertaking DMS research are available in Defence Instruction and Notices.5 This paper provides an additional resource by offering direction regarding three specific areas when undertaking qualitative research: choosing a theoretical framework, analysing the data and ethical approval. The practical implications of identifying the sample, interview skills and fieldwork are covered in a separate article in this edition.6
In research, whether it is qualitative, quantitative or mixed methods, the choice of methodology should not be predetermined, and should be the best means to address the research problem. A simple approach is to frame the potential topic as a research question, then articulate the problem to be addressed and specify the aim. The researcher can then determine what information is required to answer the question, designing a study that makes sensible, pragmatic choices between the methods of data collection and how this will be analysed. Then, use the results to answer the question. If necessary, the best approach will be to combine different types of methodologies in order to achieve the most sagacious means of answering the research question.3 The aim is to produce empirical evidence with the researcher determining direct, observable data from the samples world (Figure 1).
Simplified model of research (without hypothesis). From Punch, 2010.4
Background
Defence research relates to gathering data, either in the firmbase (peacetime setting where troops are based while preparing for role) or on deployment, from a research sample drawn from a population of personnel serving in the Armed Forces, Service families or a sample group able to provide expert commentary; this can be extended to Veterans. In the few published Defence qualitative studies, information was gathered through in-depth interviews leading to explanations that provide original insights through the interpretation of a wide range of Service personnel's emotions and behaviour.7–11
Qualitative research is diverse in the way of thinking, methods used and richness of data produced.4 Qualitative research methods result in the researcher being immersed in the subject area, with simultaneous involvement in data collection and analysis while obtaining background information from a multiplicity of resources. With all qualitative research, the aim is to deliver the study group's opinion while minimising the impact of the researcher's own bias which may result in subjective rather than objective reporting.12
Depending on the purpose and quality of data and analysis, another advantage is that valuable information can also be achieved through a limited number of 15–30 interviews.1 The requirement is to develop themes from multiple references rather than stand-alone attestations, which ensures that the researcher must explore deviant (stand-alone) cases and produce quality results. Some studies will be descriptive by organising data into categories and commenting on the information. It presents a simple picture of what happened, for example, how defence nurses use new equipment on deployment, and can be extremely useful. However, researchers should aim for an explanatory study which determines the reason for something happening and use this evolving knowledge to predict. The question is developed from the construct that there is a problem which needs a solution. To do this, the researcher needs to have an understanding of the paradigms and theories that inform research methodological frameworks.
Paradigms and meta-theories
A research paradigm is a set of assumptions about our social world; examples include positivism, post-positivism and constructivism. Positivism represents the most common paradigm or the ‘default option’, and aims to separate facts from values. Positivism treats theory as a statement of relationships between abstract concepts that cover a wide range of empirical observations. Positivists construct operational definitions of these concepts for hypothesis testing through accurate, empirical measurement that can be replicated. Positivist theories seek causes, and emphasise generality and universality.3 Military hierarchical structures and DMS research are embedded within an arena dominated by positivist views and quantitative research. Studies such as randomised controlled trials sit within this positivist model. The potential problem from a methodological perspective is that the positivist views often sit uneasily beside qualitative research theory, methodologies and designs.
Post-positivism leans towards qualitative research by accepting that issues such as the researcher's background, knowledge and values can influence what is perceived. The researcher should also be aware that constructivist theory indicates that the factors influencing a person's perception are not a uniform phenomenon, but take on a particular meaning influenced by environment, media, political views, local contexts and cultures.13 This focuses questions on asking how, when and where the research population generate their descriptions. This constructivist perspective reflects that not only does the researcher need to account for factors such as culture and context, but in order to accurately reflect the samples’ world, defence qualitative research will then need to be undertaken on deployment.
Meta-theory describes ideas about conceptions of science and includes phenomenology and hermeneutics. They present a perspective of the world and will influence the research in a variety of ways, leading to assumptions and a view of how the world functions. The chosen theory will influence the way research questions are developed and the methods that will be used to collect information. If understood, they provide a valuable resource for the researcher to produce a research framework. Research does not have to start from these perspectives; as noted above, a common start point can simply be a question that needs to be answered or a problem to be resolved. Equally important is the acknowledgement that data collected through qualitative research methods such as observation and interviews must be robust, valid, reliable and trustworthy in the empirical evidence produced. The next section will look at three meta-theories and provide brief examples of their application in a military setting.
Phenomenology, ethnography and grounded theory
Phenomenologists advocate that humans are creative agents in the construction of their social world1,4 and use qualitative methods to illuminate an understanding of their social life. Phenomenology uses analyses of the procedures of self, situational and social constitution to demonstrate how people produce a sense of social order in their everyday life.1,5 It views language, culture and common sense as objective features learned by people in the course of their lives. The researcher gathers data from multiple sources such as TV and other media sources. Information is amassed by undertaking analyses of small groups, social situations and participant observation, while intensive interviewing is widely practiced.1,6 Defence nursing is based on the concept of ‘caring’, and an understanding of Service personnel and their families. This is not particularly easy to quantify, and so Defence nurses frequently employ a phenomenological approach to offer an insight into the patient's subjective experience.1,7
Ethnography focuses on the sociology of meaning through close field observations of sociocultural phenomena. The ethnographic investigator strives to avoid theoretical preconceptions and instead to induce theory from the perspectives of the members of the culture. Typically, the researcher focuses on a community selecting subjects who are known to have an overview of the activities of the community and who can identify other representatives of that population. The areas of interest are perceived as significant by members of the society, and sampling is used to obtain information in all areas of investigation. The prime data collection method is observation with the researcher living in the culture for months or even years, and striving to understand the cultural connotations associated with items such as symbols. Ethnography is an excellent theoretical choice for covert observation and useful in areas such as criminology. Data collection is also obtained through interviewing a representative on numerous occasions to determine a cultural understanding.1,2 Ethnography presents a practical basis to detail the lives of a military cohort through participation and observation within the groups’ environment and community. This is particularly relevant to deployments in which the researcher strives to present an insider's depiction of the soldiers’ ‘real world.’
Grounded theory is an innovative, systematic means of qualitative research to provide new insights of potential value to both patients and healthcare workers.3 It moves qualitative theory beyond descriptive studies into the field of explanatory theoretical frameworks, thereby providing an awareness of the studied phenomena. The concept is that valuable information is grounded in the views and thoughts of the research sample, and a means of discovering the answer to a set of questions is to explore the issue from ‘the point of view of the actors’1,8 rather than construing hypotheses from existing theories. Grounded theorists give priority to the studied phenomena rather than the description of a setting, selecting the scenes they observe using systematic guidelines for probing beneath the surface. The more robust, ‘quantitative nature’ of grounded theory is appealing to the predominately positivist military audience. Grounded theory provides a framework for others researchers to follow. The practical methodological guidelines show how the data can be analysed and used as the study proceeds, and identifies and demonstrates how the subject population cultivate knowledge and views. Grounded theory is positioned close to the views and attestations of the research sample and it is their explanations that shape the results. Table 1 provides an example. This has been shown to be useful, resulting in reliable and valid concepts and themes that can be tested or replicated in subsequent studies. Another advantage is that the methodological structures of grounded theory can be modified to accommodate the potential constraints of the study while still resulting in robust and durable research.2 ,19
Theoretical coding and development example22
Qualitative researchers need to have a fundamental understanding of underlying paradigms and meta-theories, as these principles and terms form part of the qualitative researchers' vocabulary and act as aids when developing a research proposal. However, differing qualitative research theories offer a toolbox for collecting and analysing data and the researcher should adopt an approach that best addresses the research problem. Following the over-arching principles can help provide a structure and framework for a successful study; blind compliance can have the opposite effect. Theoretical purists will not, however, agree.
Saturation
Having assumed that the aim of qualitative research is to provide a theoretical understanding of the studied samples' experiences, the qualitative researcher assumes that there is information in the samples’ construction of the world. This will add new knowledge and insight to address extant problems or evidence to challenge traditionally held beliefs.
Qualitative research requires a consistent line of reasoning but is not a linear process, with data collection and analysis often occurring concurrently and researchers are encouraged to stop and write up ideas as they occur, placing this information into relevant situational and social contexts. From the beginning, the researcher is laying the foundation for the emerging theory and undertaking analysis to generate concepts.
During data collection, the researcher is seeking the pertinent information to identify an emerging theory. This requires refining and developing each category as the research progresses. This theoretical sampling is strategic, specific and systematic.3 As such, in grounded theory, the researchers should check emerging themes and deviations by taking an idea back to the research sample for verification and, if required, gather new data.20 Interviews and data collection continue as new categories present themselves and carry on until the emerging categories are ‘saturated’. This is achieved when gathering data no longer produce new theoretical insight or reveal new properties of the core categories, and theoretical saturation pinpoints the time to stop gathering data.3
Analysing data
Qualitative coding is a process that defines what is contained within the collected data, discovering what is happening and shaping the analytical framework. Figures, diagrams and colour can be used as a means of providing clarity and to illuminate the data. This will help the reader visualise the content and indicate the direction of travel within the analysis.2,1
Coding means categorising segments of information with a short name that simultaneously summarises and accounts for each element of data. The codes, by sticking close to the data, show how the researcher selects, separates and sorts the emerging themes and provides a framework for other researchers to follow. In grounded theory, coding is in four phases and examples from a study that explored the factors leading to depression in British Armed Forces are provided.2,2
Initial coding
The researcher reviews the interview data and names each word, each line or segment of data with the aim of remaining open to all possible theoretical implications. The developing ideas are provisional and comparative—speed and spontaneity help.
Focused line-by-line coding
New ideas emerge that were not previously recognised, and begin to shape the thematic development. Careful line-by-line coding moves the researcher to identify fit and relevance, with codes that have been constructed and developed into categories that show participants’ experiences. It provides visibility to what is happening and can be aided by colour highlighting (Table 2 and Figure 2).
Developing sub-categories during line-by-line coding
Focused coding using colour highlighting using an example of the factors leading to depression in the Army.
Axial coding
This relates to developing sub-categories into categories which reassemble the data that were splintered during initial coding to give coherence to the emerging analysis. Each of the sections is realigned to heavily referenced segments. Table 1 provides an example regarding the military macho culture and the implications for help-seeking behaviour.
Theoretical coding
This refers to how codes may relate to each other as hypotheses to be integrated into a theory, and specifying possible relationships among categories, adding accuracy and clarity. This provides the final detail for the report and can be summarised in diagrammatic forms (Figure 3); the results can then be described using relevant quotes to illuminate the information.
Theoretical model of the major influences leading to depression in the British Army.
Research proposal, ethical approval and consent
Research proposals are mainly presented for two reasons: the first aligned to an academic qualification and the second for funding, which is often in a competitive context. The proposal acts as an application providing the detail for an external audience to assess and is a considerable research process in itself. It takes significant planning, setting the research into perspective and linking to relevant literature, and providing timelines for the completion of the study. The proposal states how the researcher views the situation, what the research is about, what will be undertaken, what potentially will be learnt and what is useful about that information. It also demonstrates an understanding of the pitfalls and how to address them.
A DMS research proposal is initially presented to a Scientific Advisory Committee and if deemed to be scientifically viable is then referred to the Ministry of Defence Research Ethics Committee (MODREC). When approved, the result forms a contract. RECs generally prefer systematic and structured proposals where minor alterations should only occur when absolutely required.2,3 RECs use the proposal to judge whether the research is feasible, if it is worth doing, the candidate's ability to complete the study and whether it will produce a worthwhile report and at what level.4 In addition, there is an assessment of whether there is sufficient material to address these issues, if the researchers clearly articulated what they are trying to determine and how the results will demonstrate it. Some RECs may judge more subtle elements such as the quality of the research proposal and its presentation as an indication of the clarity of thought that went into the document.
Qualitative research is often dynamic with new data presenting new avenues to be explored. This is common in approaches such as ethnography, and the researcher needs a REC that understands this. Unfortunately, there is the potential that RECs may be over diligent, focusing on small details such as typographical errors. These aspects are of no ethical importance but will delay viable, creative and innovative operational research. Researchers may have to tolerate these frustrations, and even when REC is negotiated in a timely fashion, the Defence researcher can expect MODREC approval to take about 3 months, although it may be significantly longer and a particular burden for the inexperienced researcher, and this must be accounted for in the study timelines.
The best advice in the DMS is to contact a Defence Professor at the Royal Centre for Defence Medicine for guidance, supervision and support. It is equally important to note that similar studies have received MODREC approval.7 ,8 ,24 ,25 Unfortunately, there is no system for providing ethical approval for those on short deployments which restricts innovative or unfolding research and is a contributing factor to the lack of depth of empirical operational qualitative research.
The general principles for qualitative data are that it is ‘personal, identifiable and idiosyncratic material so that questions of confidentiality and anonymity are raised in particularly sharp form’.2,6 Ethical issues must be addressed by following UK27 and professional guidelines.2,8–30 Records must be securely kept in accordance with the Data Protection Act31 and participants provided with all relevant information to obtain informed consent. Information sheets should contain sufficient, easily understandable information to allow the subject to decide whether to join in the research or not and participants must understand they can withdraw consent at any time. This direction includes an understanding of the measures taken to ensure anonymity by strictly concealing participant's names in publications. No information should be traceable to the contributors, with lettered codes used to reference their comments rather than their names; for example ‘AA stated that …’. Each subject must also be aware of how the information will be used, for example in peer reviewed journals, presentations, television or radio and who will access the data.
Conclusions
It is not a question of whether quantitative or qualitative research is better than the other, as both are needed. But in the military setting, qualitative research is rare, yet provides an opportunity to gain empirical insight into the views of informed research samples and address long-standing military problems. In the few qualitative studies undertaken in the DMS, the results have presented novel insights into defence healthcare and information to inform and change educational programmes and clinical practice, thereby presenting an opportunity to improve the operational capability of the British Armed Forces. It is also anticipated that these guidelines will provide guidance to personnel undertaking research from other Armed Forces and studies with military Veterans.
Footnotes
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Competing interests None.
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Provenance and peer review Not commissioned; internally peer reviewed.