Qualitative Study

Affiliations.

  • 1 University of Nebraska Medical Center
  • 2 GDB Research and Statistical Consulting
  • 3 GDB Research and Statistical Consulting/McLaren Macomb Hospital
  • PMID: 29262162
  • Bookshelf ID: NBK470395

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervene or introduce treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. This review introduces the readers to some basic concepts, definitions, terminology, and application of qualitative research.

Qualitative research at its core, ask open-ended questions whose answers are not easily put into numbers such as ‘how’ and ‘why’. Due to the open-ended nature of the research questions at hand, qualitative research design is often not linear in the same way quantitative design is. One of the strengths of qualitative research is its ability to explain processes and patterns of human behavior that can be difficult to quantify. Phenomena such as experiences, attitudes, and behaviors can be difficult to accurately capture quantitatively, whereas a qualitative approach allows participants themselves to explain how, why, or what they were thinking, feeling, and experiencing at a certain time or during an event of interest. Quantifying qualitative data certainly is possible, but at its core, qualitative data is looking for themes and patterns that can be difficult to quantify and it is important to ensure that the context and narrative of qualitative work are not lost by trying to quantify something that is not meant to be quantified.

However, while qualitative research is sometimes placed in opposition to quantitative research, where they are necessarily opposites and therefore ‘compete’ against each other and the philosophical paradigms associated with each, qualitative and quantitative work are not necessarily opposites nor are they incompatible. While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Examples of Qualitative Research Approaches

Ethnography

Ethnography as a research design has its origins in social and cultural anthropology, and involves the researcher being directly immersed in the participant’s environment. Through this immersion, the ethnographer can use a variety of data collection techniques with the aim of being able to produce a comprehensive account of the social phenomena that occurred during the research period. That is to say, the researcher’s aim with ethnography is to immerse themselves into the research population and come out of it with accounts of actions, behaviors, events, etc. through the eyes of someone involved in the population. Direct involvement of the researcher with the target population is one benefit of ethnographic research because it can then be possible to find data that is otherwise very difficult to extract and record.

Grounded Theory

Grounded Theory is the “generation of a theoretical model through the experience of observing a study population and developing a comparative analysis of their speech and behavior.” As opposed to quantitative research which is deductive and tests or verifies an existing theory, grounded theory research is inductive and therefore lends itself to research that is aiming to study social interactions or experiences. In essence, Grounded Theory’s goal is to explain for example how and why an event occurs or how and why people might behave a certain way. Through observing the population, a researcher using the Grounded Theory approach can then develop a theory to explain the phenomena of interest.

Phenomenology

Phenomenology is defined as the “study of the meaning of phenomena or the study of the particular”. At first glance, it might seem that Grounded Theory and Phenomenology are quite similar, but upon careful examination, the differences can be seen. At its core, phenomenology looks to investigate experiences from the perspective of the individual. Phenomenology is essentially looking into the ‘lived experiences’ of the participants and aims to examine how and why participants behaved a certain way, from their perspective . Herein lies one of the main differences between Grounded Theory and Phenomenology. Grounded Theory aims to develop a theory for social phenomena through an examination of various data sources whereas Phenomenology focuses on describing and explaining an event or phenomena from the perspective of those who have experienced it.

Narrative Research

One of qualitative research’s strengths lies in its ability to tell a story, often from the perspective of those directly involved in it. Reporting on qualitative research involves including details and descriptions of the setting involved and quotes from participants. This detail is called ‘thick’ or ‘rich’ description and is a strength of qualitative research. Narrative research is rife with the possibilities of ‘thick’ description as this approach weaves together a sequence of events, usually from just one or two individuals, in the hopes of creating a cohesive story, or narrative. While it might seem like a waste of time to focus on such a specific, individual level, understanding one or two people’s narratives for an event or phenomenon can help to inform researchers about the influences that helped shape that narrative. The tension or conflict of differing narratives can be “opportunities for innovation”.

Research Paradigm

Research paradigms are the assumptions, norms, and standards that underpin different approaches to research. Essentially, research paradigms are the ‘worldview’ that inform research. It is valuable for researchers, both qualitative and quantitative, to understand what paradigm they are working within because understanding the theoretical basis of research paradigms allows researchers to understand the strengths and weaknesses of the approach being used and adjust accordingly. Different paradigms have different ontology and epistemologies . Ontology is defined as the "assumptions about the nature of reality” whereas epistemology is defined as the “assumptions about the nature of knowledge” that inform the work researchers do. It is important to understand the ontological and epistemological foundations of the research paradigm researchers are working within to allow for a full understanding of the approach being used and the assumptions that underpin the approach as a whole. Further, it is crucial that researchers understand their own ontological and epistemological assumptions about the world in general because their assumptions about the world will necessarily impact how they interact with research. A discussion of the research paradigm is not complete without describing positivist, postpositivist, and constructivist philosophies.

Positivist vs Postpositivist

To further understand qualitative research, we need to discuss positivist and postpositivist frameworks. Positivism is a philosophy that the scientific method can and should be applied to social as well as natural sciences. Essentially, positivist thinking insists that the social sciences should use natural science methods in its research which stems from positivist ontology that there is an objective reality that exists that is fully independent of our perception of the world as individuals. Quantitative research is rooted in positivist philosophy, which can be seen in the value it places on concepts such as causality, generalizability, and replicability.

Conversely, postpositivists argue that social reality can never be one hundred percent explained but it could be approximated. Indeed, qualitative researchers have been insisting that there are “fundamental limits to the extent to which the methods and procedures of the natural sciences could be applied to the social world” and therefore postpositivist philosophy is often associated with qualitative research. An example of positivist versus postpositivist values in research might be that positivist philosophies value hypothesis-testing, whereas postpositivist philosophies value the ability to formulate a substantive theory.

Constructivist

Constructivism is a subcategory of postpositivism. Most researchers invested in postpositivist research are constructivist as well, meaning they think there is no objective external reality that exists but rather that reality is constructed. Constructivism is a theoretical lens that emphasizes the dynamic nature of our world. “Constructivism contends that individuals’ views are directly influenced by their experiences, and it is these individual experiences and views that shape their perspective of reality”. Essentially, Constructivist thought focuses on how ‘reality’ is not a fixed certainty and experiences, interactions, and backgrounds give people a unique view of the world. Constructivism contends, unlike in positivist views, that there is not necessarily an ‘objective’ reality we all experience. This is the ‘relativist’ ontological view that reality and the world we live in are dynamic and socially constructed. Therefore, qualitative scientific knowledge can be inductive as well as deductive.”

So why is it important to understand the differences in assumptions that different philosophies and approaches to research have? Fundamentally, the assumptions underpinning the research tools a researcher selects provide an overall base for the assumptions the rest of the research will have and can even change the role of the researcher themselves. For example, is the researcher an ‘objective’ observer such as in positivist quantitative work? Or is the researcher an active participant in the research itself, as in postpositivist qualitative work? Understanding the philosophical base of the research undertaken allows researchers to fully understand the implications of their work and their role within the research, as well as reflect on their own positionality and bias as it pertains to the research they are conducting.

Data Sampling

The better the sample represents the intended study population, the more likely the researcher is to encompass the varying factors at play. The following are examples of participant sampling and selection:

Purposive sampling- selection based on the researcher’s rationale in terms of being the most informative.

Criterion sampling-selection based on pre-identified factors.

Convenience sampling- selection based on availability.

Snowball sampling- the selection is by referral from other participants or people who know potential participants.

Extreme case sampling- targeted selection of rare cases.

Typical case sampling-selection based on regular or average participants.

Data Collection and Analysis

Qualitative research uses several techniques including interviews, focus groups, and observation. [1] [2] [3] Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one on one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be a participant-observer to share the experiences of the subject or a non-participant or detached observer.

While quantitative research design prescribes a controlled environment for data collection, qualitative data collection may be in a central location or in the environment of the participants, depending on the study goals and design. Qualitative research could amount to a large amount of data. Data is transcribed which may then be coded manually or with the use of Computer Assisted Qualitative Data Analysis Software or CAQDAS such as ATLAS.ti or NVivo.

After the coding process, qualitative research results could be in various formats. It could be a synthesis and interpretation presented with excerpts from the data. Results also could be in the form of themes and theory or model development.

Dissemination

To standardize and facilitate the dissemination of qualitative research outcomes, the healthcare team can use two reporting standards. The Consolidated Criteria for Reporting Qualitative Research or COREQ is a 32-item checklist for interviews and focus groups. The Standards for Reporting Qualitative Research (SRQR) is a checklist covering a wider range of qualitative research.

Examples of Application

Many times a research question will start with qualitative research. The qualitative research will help generate the research hypothesis which can be tested with quantitative methods. After the data is collected and analyzed with quantitative methods, a set of qualitative methods can be used to dive deeper into the data for a better understanding of what the numbers truly mean and their implications. The qualitative methods can then help clarify the quantitative data and also help refine the hypothesis for future research. Furthermore, with qualitative research researchers can explore subjects that are poorly studied with quantitative methods. These include opinions, individual's actions, and social science research.

A good qualitative study design starts with a goal or objective. This should be clearly defined or stated. The target population needs to be specified. A method for obtaining information from the study population must be carefully detailed to ensure there are no omissions of part of the target population. A proper collection method should be selected which will help obtain the desired information without overly limiting the collected data because many times, the information sought is not well compartmentalized or obtained. Finally, the design should ensure adequate methods for analyzing the data. An example may help better clarify some of the various aspects of qualitative research.

A researcher wants to decrease the number of teenagers who smoke in their community. The researcher could begin by asking current teen smokers why they started smoking through structured or unstructured interviews (qualitative research). The researcher can also get together a group of current teenage smokers and conduct a focus group to help brainstorm factors that may have prevented them from starting to smoke (qualitative research).

In this example, the researcher has used qualitative research methods (interviews and focus groups) to generate a list of ideas of both why teens start to smoke as well as factors that may have prevented them from starting to smoke. Next, the researcher compiles this data. The research found that, hypothetically, peer pressure, health issues, cost, being considered “cool,” and rebellious behavior all might increase or decrease the likelihood of teens starting to smoke.

The researcher creates a survey asking teen participants to rank how important each of the above factors is in either starting smoking (for current smokers) or not smoking (for current non-smokers). This survey provides specific numbers (ranked importance of each factor) and is thus a quantitative research tool.

The researcher can use the results of the survey to focus efforts on the one or two highest-ranked factors. Let us say the researcher found that health was the major factor that keeps teens from starting to smoke, and peer pressure was the major factor that contributed to teens to start smoking. The researcher can go back to qualitative research methods to dive deeper into each of these for more information. The researcher wants to focus on how to keep teens from starting to smoke, so they focus on the peer pressure aspect.

The researcher can conduct interviews and/or focus groups (qualitative research) about what types and forms of peer pressure are commonly encountered, where the peer pressure comes from, and where smoking first starts. The researcher hypothetically finds that peer pressure often occurs after school at the local teen hangouts, mostly the local park. The researcher also hypothetically finds that peer pressure comes from older, current smokers who provide the cigarettes.

The researcher could further explore this observation made at the local teen hangouts (qualitative research) and take notes regarding who is smoking, who is not, and what observable factors are at play for peer pressure of smoking. The researcher finds a local park where many local teenagers hang out and see that a shady, overgrown area of the park is where the smokers tend to hang out. The researcher notes the smoking teenagers buy their cigarettes from a local convenience store adjacent to the park where the clerk does not check identification before selling cigarettes. These observations fall under qualitative research.

If the researcher returns to the park and counts how many individuals smoke in each region of the park, this numerical data would be quantitative research. Based on the researcher's efforts thus far, they conclude that local teen smoking and teenagers who start to smoke may decrease if there are fewer overgrown areas of the park and the local convenience store does not sell cigarettes to underage individuals.

The researcher could try to have the parks department reassess the shady areas to make them less conducive to the smokers or identify how to limit the sales of cigarettes to underage individuals by the convenience store. The researcher would then cycle back to qualitative methods of asking at-risk population their perceptions of the changes, what factors are still at play, as well as quantitative research that includes teen smoking rates in the community, the incidence of new teen smokers, among others.

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  • Introduction
  • Issues of Concern
  • Clinical Significance
  • Enhancing Healthcare Team Outcomes
  • Review Questions

Publication types

  • Study Guide

About Journal

American Journal of Qualitative Research (AJQR)  is a quarterly peer-reviewed academic journal that publishes qualitative research articles from a number of social science disciplines such as psychology, health science, sociology, criminology, education, political science, and administrative studies. The journal is an international and interdisciplinary focus and greatly welcomes papers from all countries. The journal offers an intellectual platform for researchers, practitioners, administrators, and policymakers to contribute and promote qualitative research and analysis.

ISSN: 2576-2141

Call for Papers- American Journal of Qualitative Research

American Journal of Qualitative Research (AJQR) welcomes original research articles and book reviews for its next issue. The AJQR is a quarterly and peer-reviewed journal published in February, May, August, and November.

We are seeking submissions for a forthcoming issue published in February 2024. The paper should be written in professional English. The length of 6000-10000 words is preferred. All manuscripts should be prepared in MS Word format and submitted online: https://www.editorialpark.com/ajqr

For any further information about the journal, please visit its website: https://www.ajqr.org

Submission Deadline: November 15, 2023

Announcement 

Dear AJQR Readers, 

Due to the high volume of submissions in the American Journal of Qualitative Research , the editorial board decided to publish quarterly since 2023.

Volume 8, Issue 1

Current issue.

Social distancing requirements resulted in many people working from home in the United Kingdom during the COVID-19 pandemic. The topic of working from home was often discussed in the media and online during the pandemic, but little was known about how quality of life (QOL) and remote working interfaced. The purpose of this study was to describe QOL while working from home during the COVID-19 pandemic. The novel topic, unique methodological approach of the General Online Qualitative Study ( D’Abundo & Franco, 2022a), and the strategic Social Distancing Sampling ( D’Abundo & Franco, 2022c) resulted in significant participation throughout the world (n = 709). The United Kingdom subset of participants (n = 234) is the focus of this article. This big qual, large qualitative study (n >100) included the principal investigator-developed, open-ended, online questionnaire entitled the “Quality of Life Home Workplace Questionnaire (QOLHWQ)” and demographic questions. Data were collected peak-pandemic from July to September 2020. Most participants cited increased QOL due to having more time with family/kids/partners/pets, a more comfortable work environment while being at home, and less commuting to work. The most cited issue associated with negative QOL was social isolation. As restrictions have been lifted and public health emergency declarations have been terminated during the post-peak era of the COVID-19 pandemic, the potential for future public health emergencies requiring social distancing still exists. To promote QOL and work-life balance for employees working remotely in the United Kingdom, stakeholders could develop social support networks and create effective planning initiatives to prevent social isolation and maximize the benefits of remote working experiences for both employees and organizations.

Keywords: qualitative research, quality of life, remote work, telework, United Kingdom, work from home.

(no abstract)

This essay reviews classic works on the philosophy of science and contemporary pedagogical guides to scientific inquiry in order to present a discussion of the three logics that underlie qualitative research in political science. The first logic, epistemology, relates to the essence of research as a scientific endeavor and is framed as a debate between positivist and interpretivist orientations within the discipline of political science. The second logic, ontology, relates to the approach that research takes to investigating the empirical world and is framed as a debate between positivist qualitative and quantitative orientations, which together constitute the vast majority of mainstream researchers within the discipline. The third logic, methodology, relates to the means by which research aspires to reach its scientific ends and is framed as a debate among positivist qualitative orientations. Additionally, the essay discusses the present state of qualitative research in the discipline of political science, reviews the various ways in which qualitative research is defined in the relevant literature, addresses the limitations and trade-offs that are inherently associated with the aforementioned logics of qualitative research, explores multimethod approaches to remedying these issues, and proposes avenues for acquiring further information on the topics discussed.

Keywords: qualitative research, epistemology, ontology, methodology

This paper examines the phenomenology of diagnostic crossover in eating disorders, the movement within or between feeding and eating disorder subtypes or diagnoses over time, in two young women who experienced multiple changes in eating disorder diagnosis over 5 years. Using interpretative phenomenological analysis, this study found that transitioning between different diagnostic labels, specifically between bulimia nervosa and anorexia nervosa binge/purge subtype, was experienced as disempowering, stigmatizing, and unhelpful. The findings in this study offer novel evidence that, from the perspective of individuals diagnosed with EDs, using BMI as an indicator of the presence, severity, or change of an ED may have adverse consequences for well-being and recovery and may lead to mischaracterization or misclassification of health status. The narratives discussed in this paper highlight the need for more person-centered practices in the context of diagnostic crossover. Including the perspectives of those with lived experience can help care providers working with individuals with eating disorders gain an in-depth understanding of the potential personal impact of diagnosis changing and inform discussions around developing person-focused diagnostic practices.

Keywords: feeding and eating disorders, bulimia nervosa, diagnostic labels, diagnostic crossover, illness narrative

Often among the first witnesses to child trauma, educators and therapists are on the frontline of an unfolding and multi-pronged occupational crisis. For educators, lack of support and secondary traumatic stress (STS) appear to be contributing to an epidemic in professional attrition. Similarly, therapists who do not prioritize self-care can feel depleted of energy and optimism. The purpose of this phenomenological study was to examine how bearing witness to the traumatic narratives of children impacts similar helping professionals. The study also sought to extrapolate the similarities and differences between compassion fatigue and secondary trauma across these two disciplines. Exploring the common factors and subjective individual experiences related to occupational stress across these two fields may foster a more complete picture of the delicate nature of working with traumatized children and the importance of successful self-care strategies. Utilizing Constructivist Self-Development Theory (CSDT) and focus group interviews, the study explores the significant risk of STS facing both educators and therapists.

Keywords: qualitative, secondary traumatic stress, self-care, child trauma, educators, therapists.

This study explored the lived experiences of residents of the Gulf Coast in the USA during Hurricane Katrina, which made landfall in August 2005 and caused insurmountable destruction throughout the area. A heuristic process and thematic analysis were employed to draw observations and conclusions about the lived experiences of each participant and make meaning through similar thoughts, feelings, and themes that emerged in the analysis of the data. Six themes emerged: (1) fear, (2) loss, (3) anger, (4) support, (5) spirituality, and (6) resilience. The results of this study allude to the possible psychological outcomes as a result of experiencing a traumatic event and provide an outline of what the psychological experience of trauma might entail. The current research suggests that preparedness and expectation are key to resilience and that people who feel that they have power over their situation fare better than those who do not.

Keywords: mass trauma, resilience, loss, natural disaster, mental health.

Women from rural, low-income backgrounds holding positions within the academy are the exception and not the rule. Most women faculty in the academy are from urban/suburban areas and middle- and upper-income family backgrounds. As women faculty who do not represent this norm, our primary goal with this article is to focus on the unique barriers we experienced as girls from rural, low-income areas in K-12 schools that influenced the possibilities for successfully transitioning to and engaging with higher education. We employed a qualitative duoethnographic and narrative research design to respond to the research questions, and we generated our data through semi-structured, critical, ethnographic dialogic conversations. Our duoethnographic-narrative analyses revealed six major themes: (1) independence and other   benefits of having a working-class mom; (2) crashing into middle-class norms and expectations; (3) lucking and falling into college; (4) fish out of water; (5) overcompensating, playing middle class, walking on eggshells, and pushing back; and (6) transitioning from a working-class kid to a working class academic, which we discuss in relation to our own educational attainment.

Keywords: rurality, working-class, educational attainment, duoethnography, higher education, women.

This article draws on the findings of a qualitative study that focused on the perspectives of four Indian American mothers of youth with developmental disabilities on the process of transitioning from school to post-school environments. Data were collected through in-depth ethnographic interviews. The findings indicate that in their efforts to support their youth with developmental disabilities, the mothers themselves navigate multiple transitions across countries, constructs, dreams, systems of schooling, and services. The mothers’ perspectives have to be understood against the larger context of their experiences as citizens of this country as well as members of the South Asian diaspora. The mothers’ views on services, their journey, their dreams for their youth, and their interpretation of the ideas anchored in current conversations on transition are continually evolving. Their attempts to maintain their resilience and their indigenous understandings while simultaneously negotiating their experiences in the United States with supporting their youth are discussed.  

Keywords: Indian-American mothers, transitioning, diaspora, disability, dreams.

This study explored the influence of yoga on practitioners’ lives ‘off the mat’ through a phenomenological lens. Central to the study was the lived experience of yoga in a purposive sample of self-identified New Zealand practitioners (n=38; 89.5% female; aged 18 to 65 years; 60.5% aged 36 to 55 years). The study’s aim was to explore whether habitual yoga practitioners experience any pro-health downstream effects of their practice ‘off the mat’ via their lived experience of yoga. A qualitative mixed methodology was applied via a phenomenological lens that explicitly acknowledged the researcher’s own experience of the research topic. Qualitative methods comprised an open-ended online survey for all participants (n=38), followed by in-depth semi-structured interviews (n=8) on a randomized subset. Quantitative methods included online outcome measures (health habits, self-efficacy, interoceptive awareness, and physical activity), practice component data (tenure, dose, yoga styles, yoga teacher status, meditation frequency), and socio-demographics. This paper highlights the qualitative findings emerging from participant narratives. Reported benefits of practice included the provision of a filter through which to engage with life and the experience of self-regulation and mindfulness ‘off the mat’. Practitioners experienced yoga as a self-sustaining positive resource via self-regulation guided by an embodied awareness. The key narrative to emerge was an attunement to embodiment through movement. Embodied movement can elicit self-regulatory pathways that support health behavior.

Keywords: embodiment, habit, interoception, mindfulness, movement practice, qualitative, self-regulation, yoga.

Historically and in the present day, Black women’s positionality in the U.S. has paradoxically situated them in a society where they are both intrinsically essential and treated as expendable. This positionality, known as gendered racism, manifests commonly in professional environments and results in myriad harms. In response, Black women have developed, honed, and practiced a range of coping styles to mitigate the insidious effects of gendered racism. While often effective in the short-term, these techniques frequently complicate Black women’s well-being. For Black female clinicians who experience gendered racism and work on the frontlines of community mental health, myriad bio-psycho-social-spiritual harms compound. This project provided an opportunity for Black female clinicians from across the U.S. to share their experiences during the dual pandemics of COVID-19 and anti-Black violence. I conducted in-depth interviews with clinicians (n=14) between the ages of 30 and 58. Using the Listening Guide voice-centered approach to data generation and analysis, I identified four voices to help answer this project’s central question: How do you experience being a Black female clinician in the U.S.? The voices of self, pride, vigilance, and mediating narrated the complex ways participants experienced their workplaces. This complexity seemed to be context-specific, depending on whether the clinicians worked in predominantly White workplaces (PWW), a mix of PWW and private practice, or private practice exclusively. Participants who worked only in PWW experienced the greatest stress, oppression, and burnout risk, while participants who worked exclusively in private practice reported more joy, more authenticity, and more job satisfaction. These findings have implications for mentoring, supporting, and retaining Black female clinicians.

Keywords: Black female clinicians, professional experiences, gendered racism, Listening Guide voice-centered approach.

The purpose of this article is to speak directly to the paucity of research regarding Dominican American women and identity narratives. To do so, this article uses the Listening Guide Method of Qualitative Inquiry (Gilligan, et al., 2006) to explore how 1.5 and second-generation Dominican American women narrated their experiences of individual identity within American cultural contexts and constructs. The results draw from the emergence of themes across six participant interviews and showed two distinct voices: The Voice of Cultural Explanation and the Tides of Dominican American Female Identity. Narrative examples from five participants are offered to illustrate where 1.5 and second-generation Dominican American women negotiate their identity narratives at the intersection of their Dominican and American selves. The article offers two conclusions. One, that participant women use the Voice of Cultural Explanation in order to discuss their identity as reflected within the broad cultural tensions of their daily lives. Two, that the Tides of Dominican American Female Identity are used to express strong emotions that manifest within their personal narratives as the unwanted distance from either the Dominican or American parts of their person.

Keywords: Dominican American, women, identity, the Listening Guide, narratives

  • Open access
  • Published: 27 May 2020

How to use and assess qualitative research methods

  • Loraine Busetto   ORCID: orcid.org/0000-0002-9228-7875 1 ,
  • Wolfgang Wick 1 , 2 &
  • Christoph Gumbinger 1  

Neurological Research and Practice volume  2 , Article number:  14 ( 2020 ) Cite this article

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This paper aims to provide an overview of the use and assessment of qualitative research methods in the health sciences. Qualitative research can be defined as the study of the nature of phenomena and is especially appropriate for answering questions of why something is (not) observed, assessing complex multi-component interventions, and focussing on intervention improvement. The most common methods of data collection are document study, (non-) participant observations, semi-structured interviews and focus groups. For data analysis, field-notes and audio-recordings are transcribed into protocols and transcripts, and coded using qualitative data management software. Criteria such as checklists, reflexivity, sampling strategies, piloting, co-coding, member-checking and stakeholder involvement can be used to enhance and assess the quality of the research conducted. Using qualitative in addition to quantitative designs will equip us with better tools to address a greater range of research problems, and to fill in blind spots in current neurological research and practice.

The aim of this paper is to provide an overview of qualitative research methods, including hands-on information on how they can be used, reported and assessed. This article is intended for beginning qualitative researchers in the health sciences as well as experienced quantitative researchers who wish to broaden their understanding of qualitative research.

What is qualitative research?

Qualitative research is defined as “the study of the nature of phenomena”, including “their quality, different manifestations, the context in which they appear or the perspectives from which they can be perceived” , but excluding “their range, frequency and place in an objectively determined chain of cause and effect” [ 1 ]. This formal definition can be complemented with a more pragmatic rule of thumb: qualitative research generally includes data in form of words rather than numbers [ 2 ].

Why conduct qualitative research?

Because some research questions cannot be answered using (only) quantitative methods. For example, one Australian study addressed the issue of why patients from Aboriginal communities often present late or not at all to specialist services offered by tertiary care hospitals. Using qualitative interviews with patients and staff, it found one of the most significant access barriers to be transportation problems, including some towns and communities simply not having a bus service to the hospital [ 3 ]. A quantitative study could have measured the number of patients over time or even looked at possible explanatory factors – but only those previously known or suspected to be of relevance. To discover reasons for observed patterns, especially the invisible or surprising ones, qualitative designs are needed.

While qualitative research is common in other fields, it is still relatively underrepresented in health services research. The latter field is more traditionally rooted in the evidence-based-medicine paradigm, as seen in " research that involves testing the effectiveness of various strategies to achieve changes in clinical practice, preferably applying randomised controlled trial study designs (...) " [ 4 ]. This focus on quantitative research and specifically randomised controlled trials (RCT) is visible in the idea of a hierarchy of research evidence which assumes that some research designs are objectively better than others, and that choosing a "lesser" design is only acceptable when the better ones are not practically or ethically feasible [ 5 , 6 ]. Others, however, argue that an objective hierarchy does not exist, and that, instead, the research design and methods should be chosen to fit the specific research question at hand – "questions before methods" [ 2 , 7 , 8 , 9 ]. This means that even when an RCT is possible, some research problems require a different design that is better suited to addressing them. Arguing in JAMA, Berwick uses the example of rapid response teams in hospitals, which he describes as " a complex, multicomponent intervention – essentially a process of social change" susceptible to a range of different context factors including leadership or organisation history. According to him, "[in] such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect" [ 8 ] . Instead of limiting oneself to RCTs, Berwick recommends embracing a wider range of methods , including qualitative ones, which for "these specific applications, (...) are not compromises in learning how to improve; they are superior" [ 8 ].

Research problems that can be approached particularly well using qualitative methods include assessing complex multi-component interventions or systems (of change), addressing questions beyond “what works”, towards “what works for whom when, how and why”, and focussing on intervention improvement rather than accreditation [ 7 , 9 , 10 , 11 , 12 ]. Using qualitative methods can also help shed light on the “softer” side of medical treatment. For example, while quantitative trials can measure the costs and benefits of neuro-oncological treatment in terms of survival rates or adverse effects, qualitative research can help provide a better understanding of patient or caregiver stress, visibility of illness or out-of-pocket expenses.

How to conduct qualitative research?

Given that qualitative research is characterised by flexibility, openness and responsivity to context, the steps of data collection and analysis are not as separate and consecutive as they tend to be in quantitative research [ 13 , 14 ]. As Fossey puts it : “sampling, data collection, analysis and interpretation are related to each other in a cyclical (iterative) manner, rather than following one after another in a stepwise approach” [ 15 ]. The researcher can make educated decisions with regard to the choice of method, how they are implemented, and to which and how many units they are applied [ 13 ]. As shown in Fig.  1 , this can involve several back-and-forth steps between data collection and analysis where new insights and experiences can lead to adaption and expansion of the original plan. Some insights may also necessitate a revision of the research question and/or the research design as a whole. The process ends when saturation is achieved, i.e. when no relevant new information can be found (see also below: sampling and saturation). For reasons of transparency, it is essential for all decisions as well as the underlying reasoning to be well-documented.

figure 1

Iterative research process

While it is not always explicitly addressed, qualitative methods reflect a different underlying research paradigm than quantitative research (e.g. constructivism or interpretivism as opposed to positivism). The choice of methods can be based on the respective underlying substantive theory or theoretical framework used by the researcher [ 2 ].

Data collection

The methods of qualitative data collection most commonly used in health research are document study, observations, semi-structured interviews and focus groups [ 1 , 14 , 16 , 17 ].

Document study

Document study (also called document analysis) refers to the review by the researcher of written materials [ 14 ]. These can include personal and non-personal documents such as archives, annual reports, guidelines, policy documents, diaries or letters.

Observations

Observations are particularly useful to gain insights into a certain setting and actual behaviour – as opposed to reported behaviour or opinions [ 13 ]. Qualitative observations can be either participant or non-participant in nature. In participant observations, the observer is part of the observed setting, for example a nurse working in an intensive care unit [ 18 ]. In non-participant observations, the observer is “on the outside looking in”, i.e. present in but not part of the situation, trying not to influence the setting by their presence. Observations can be planned (e.g. for 3 h during the day or night shift) or ad hoc (e.g. as soon as a stroke patient arrives at the emergency room). During the observation, the observer takes notes on everything or certain pre-determined parts of what is happening around them, for example focusing on physician-patient interactions or communication between different professional groups. Written notes can be taken during or after the observations, depending on feasibility (which is usually lower during participant observations) and acceptability (e.g. when the observer is perceived to be judging the observed). Afterwards, these field notes are transcribed into observation protocols. If more than one observer was involved, field notes are taken independently, but notes can be consolidated into one protocol after discussions. Advantages of conducting observations include minimising the distance between the researcher and the researched, the potential discovery of topics that the researcher did not realise were relevant and gaining deeper insights into the real-world dimensions of the research problem at hand [ 18 ].

Semi-structured interviews

Hijmans & Kuyper describe qualitative interviews as “an exchange with an informal character, a conversation with a goal” [ 19 ]. Interviews are used to gain insights into a person’s subjective experiences, opinions and motivations – as opposed to facts or behaviours [ 13 ]. Interviews can be distinguished by the degree to which they are structured (i.e. a questionnaire), open (e.g. free conversation or autobiographical interviews) or semi-structured [ 2 , 13 ]. Semi-structured interviews are characterized by open-ended questions and the use of an interview guide (or topic guide/list) in which the broad areas of interest, sometimes including sub-questions, are defined [ 19 ]. The pre-defined topics in the interview guide can be derived from the literature, previous research or a preliminary method of data collection, e.g. document study or observations. The topic list is usually adapted and improved at the start of the data collection process as the interviewer learns more about the field [ 20 ]. Across interviews the focus on the different (blocks of) questions may differ and some questions may be skipped altogether (e.g. if the interviewee is not able or willing to answer the questions or for concerns about the total length of the interview) [ 20 ]. Qualitative interviews are usually not conducted in written format as it impedes on the interactive component of the method [ 20 ]. In comparison to written surveys, qualitative interviews have the advantage of being interactive and allowing for unexpected topics to emerge and to be taken up by the researcher. This can also help overcome a provider or researcher-centred bias often found in written surveys, which by nature, can only measure what is already known or expected to be of relevance to the researcher. Interviews can be audio- or video-taped; but sometimes it is only feasible or acceptable for the interviewer to take written notes [ 14 , 16 , 20 ].

Focus groups

Focus groups are group interviews to explore participants’ expertise and experiences, including explorations of how and why people behave in certain ways [ 1 ]. Focus groups usually consist of 6–8 people and are led by an experienced moderator following a topic guide or “script” [ 21 ]. They can involve an observer who takes note of the non-verbal aspects of the situation, possibly using an observation guide [ 21 ]. Depending on researchers’ and participants’ preferences, the discussions can be audio- or video-taped and transcribed afterwards [ 21 ]. Focus groups are useful for bringing together homogeneous (to a lesser extent heterogeneous) groups of participants with relevant expertise and experience on a given topic on which they can share detailed information [ 21 ]. Focus groups are a relatively easy, fast and inexpensive method to gain access to information on interactions in a given group, i.e. “the sharing and comparing” among participants [ 21 ]. Disadvantages include less control over the process and a lesser extent to which each individual may participate. Moreover, focus group moderators need experience, as do those tasked with the analysis of the resulting data. Focus groups can be less appropriate for discussing sensitive topics that participants might be reluctant to disclose in a group setting [ 13 ]. Moreover, attention must be paid to the emergence of “groupthink” as well as possible power dynamics within the group, e.g. when patients are awed or intimidated by health professionals.

Choosing the “right” method

As explained above, the school of thought underlying qualitative research assumes no objective hierarchy of evidence and methods. This means that each choice of single or combined methods has to be based on the research question that needs to be answered and a critical assessment with regard to whether or to what extent the chosen method can accomplish this – i.e. the “fit” between question and method [ 14 ]. It is necessary for these decisions to be documented when they are being made, and to be critically discussed when reporting methods and results.

Let us assume that our research aim is to examine the (clinical) processes around acute endovascular treatment (EVT), from the patient’s arrival at the emergency room to recanalization, with the aim to identify possible causes for delay and/or other causes for sub-optimal treatment outcome. As a first step, we could conduct a document study of the relevant standard operating procedures (SOPs) for this phase of care – are they up-to-date and in line with current guidelines? Do they contain any mistakes, irregularities or uncertainties that could cause delays or other problems? Regardless of the answers to these questions, the results have to be interpreted based on what they are: a written outline of what care processes in this hospital should look like. If we want to know what they actually look like in practice, we can conduct observations of the processes described in the SOPs. These results can (and should) be analysed in themselves, but also in comparison to the results of the document analysis, especially as regards relevant discrepancies. Do the SOPs outline specific tests for which no equipment can be observed or tasks to be performed by specialized nurses who are not present during the observation? It might also be possible that the written SOP is outdated, but the actual care provided is in line with current best practice. In order to find out why these discrepancies exist, it can be useful to conduct interviews. Are the physicians simply not aware of the SOPs (because their existence is limited to the hospital’s intranet) or do they actively disagree with them or does the infrastructure make it impossible to provide the care as described? Another rationale for adding interviews is that some situations (or all of their possible variations for different patient groups or the day, night or weekend shift) cannot practically or ethically be observed. In this case, it is possible to ask those involved to report on their actions – being aware that this is not the same as the actual observation. A senior physician’s or hospital manager’s description of certain situations might differ from a nurse’s or junior physician’s one, maybe because they intentionally misrepresent facts or maybe because different aspects of the process are visible or important to them. In some cases, it can also be relevant to consider to whom the interviewee is disclosing this information – someone they trust, someone they are otherwise not connected to, or someone they suspect or are aware of being in a potentially “dangerous” power relationship to them. Lastly, a focus group could be conducted with representatives of the relevant professional groups to explore how and why exactly they provide care around EVT. The discussion might reveal discrepancies (between SOPs and actual care or between different physicians) and motivations to the researchers as well as to the focus group members that they might not have been aware of themselves. For the focus group to deliver relevant information, attention has to be paid to its composition and conduct, for example, to make sure that all participants feel safe to disclose sensitive or potentially problematic information or that the discussion is not dominated by (senior) physicians only. The resulting combination of data collection methods is shown in Fig.  2 .

figure 2

Possible combination of data collection methods

Attributions for icons: “Book” by Serhii Smirnov, “Interview” by Adrien Coquet, FR, “Magnifying Glass” by anggun, ID, “Business communication” by Vectors Market; all from the Noun Project

The combination of multiple data source as described for this example can be referred to as “triangulation”, in which multiple measurements are carried out from different angles to achieve a more comprehensive understanding of the phenomenon under study [ 22 , 23 ].

Data analysis

To analyse the data collected through observations, interviews and focus groups these need to be transcribed into protocols and transcripts (see Fig.  3 ). Interviews and focus groups can be transcribed verbatim , with or without annotations for behaviour (e.g. laughing, crying, pausing) and with or without phonetic transcription of dialects and filler words, depending on what is expected or known to be relevant for the analysis. In the next step, the protocols and transcripts are coded , that is, marked (or tagged, labelled) with one or more short descriptors of the content of a sentence or paragraph [ 2 , 15 , 23 ]. Jansen describes coding as “connecting the raw data with “theoretical” terms” [ 20 ]. In a more practical sense, coding makes raw data sortable. This makes it possible to extract and examine all segments describing, say, a tele-neurology consultation from multiple data sources (e.g. SOPs, emergency room observations, staff and patient interview). In a process of synthesis and abstraction, the codes are then grouped, summarised and/or categorised [ 15 , 20 ]. The end product of the coding or analysis process is a descriptive theory of the behavioural pattern under investigation [ 20 ]. The coding process is performed using qualitative data management software, the most common ones being InVivo, MaxQDA and Atlas.ti. It should be noted that these are data management tools which support the analysis performed by the researcher(s) [ 14 ].

figure 3

From data collection to data analysis

Attributions for icons: see Fig. 2 , also “Speech to text” by Trevor Dsouza, “Field Notes” by Mike O’Brien, US, “Voice Record” by ProSymbols, US, “Inspection” by Made, AU, and “Cloud” by Graphic Tigers; all from the Noun Project

How to report qualitative research?

Protocols of qualitative research can be published separately and in advance of the study results. However, the aim is not the same as in RCT protocols, i.e. to pre-define and set in stone the research questions and primary or secondary endpoints. Rather, it is a way to describe the research methods in detail, which might not be possible in the results paper given journals’ word limits. Qualitative research papers are usually longer than their quantitative counterparts to allow for deep understanding and so-called “thick description”. In the methods section, the focus is on transparency of the methods used, including why, how and by whom they were implemented in the specific study setting, so as to enable a discussion of whether and how this may have influenced data collection, analysis and interpretation. The results section usually starts with a paragraph outlining the main findings, followed by more detailed descriptions of, for example, the commonalities, discrepancies or exceptions per category [ 20 ]. Here it is important to support main findings by relevant quotations, which may add information, context, emphasis or real-life examples [ 20 , 23 ]. It is subject to debate in the field whether it is relevant to state the exact number or percentage of respondents supporting a certain statement (e.g. “Five interviewees expressed negative feelings towards XYZ”) [ 21 ].

How to combine qualitative with quantitative research?

Qualitative methods can be combined with other methods in multi- or mixed methods designs, which “[employ] two or more different methods [ …] within the same study or research program rather than confining the research to one single method” [ 24 ]. Reasons for combining methods can be diverse, including triangulation for corroboration of findings, complementarity for illustration and clarification of results, expansion to extend the breadth and range of the study, explanation of (unexpected) results generated with one method with the help of another, or offsetting the weakness of one method with the strength of another [ 1 , 17 , 24 , 25 , 26 ]. The resulting designs can be classified according to when, why and how the different quantitative and/or qualitative data strands are combined. The three most common types of mixed method designs are the convergent parallel design , the explanatory sequential design and the exploratory sequential design. The designs with examples are shown in Fig.  4 .

figure 4

Three common mixed methods designs

In the convergent parallel design, a qualitative study is conducted in parallel to and independently of a quantitative study, and the results of both studies are compared and combined at the stage of interpretation of results. Using the above example of EVT provision, this could entail setting up a quantitative EVT registry to measure process times and patient outcomes in parallel to conducting the qualitative research outlined above, and then comparing results. Amongst other things, this would make it possible to assess whether interview respondents’ subjective impressions of patients receiving good care match modified Rankin Scores at follow-up, or whether observed delays in care provision are exceptions or the rule when compared to door-to-needle times as documented in the registry. In the explanatory sequential design, a quantitative study is carried out first, followed by a qualitative study to help explain the results from the quantitative study. This would be an appropriate design if the registry alone had revealed relevant delays in door-to-needle times and the qualitative study would be used to understand where and why these occurred, and how they could be improved. In the exploratory design, the qualitative study is carried out first and its results help informing and building the quantitative study in the next step [ 26 ]. If the qualitative study around EVT provision had shown a high level of dissatisfaction among the staff members involved, a quantitative questionnaire investigating staff satisfaction could be set up in the next step, informed by the qualitative study on which topics dissatisfaction had been expressed. Amongst other things, the questionnaire design would make it possible to widen the reach of the research to more respondents from different (types of) hospitals, regions, countries or settings, and to conduct sub-group analyses for different professional groups.

How to assess qualitative research?

A variety of assessment criteria and lists have been developed for qualitative research, ranging in their focus and comprehensiveness [ 14 , 17 , 27 ]. However, none of these has been elevated to the “gold standard” in the field. In the following, we therefore focus on a set of commonly used assessment criteria that, from a practical standpoint, a researcher can look for when assessing a qualitative research report or paper.

Assessors should check the authors’ use of and adherence to the relevant reporting checklists (e.g. Standards for Reporting Qualitative Research (SRQR)) to make sure all items that are relevant for this type of research are addressed [ 23 , 28 ]. Discussions of quantitative measures in addition to or instead of these qualitative measures can be a sign of lower quality of the research (paper). Providing and adhering to a checklist for qualitative research contributes to an important quality criterion for qualitative research, namely transparency [ 15 , 17 , 23 ].

Reflexivity

While methodological transparency and complete reporting is relevant for all types of research, some additional criteria must be taken into account for qualitative research. This includes what is called reflexivity, i.e. sensitivity to the relationship between the researcher and the researched, including how contact was established and maintained, or the background and experience of the researcher(s) involved in data collection and analysis. Depending on the research question and population to be researched this can be limited to professional experience, but it may also include gender, age or ethnicity [ 17 , 27 ]. These details are relevant because in qualitative research, as opposed to quantitative research, the researcher as a person cannot be isolated from the research process [ 23 ]. It may influence the conversation when an interviewed patient speaks to an interviewer who is a physician, or when an interviewee is asked to discuss a gynaecological procedure with a male interviewer, and therefore the reader must be made aware of these details [ 19 ].

Sampling and saturation

The aim of qualitative sampling is for all variants of the objects of observation that are deemed relevant for the study to be present in the sample “ to see the issue and its meanings from as many angles as possible” [ 1 , 16 , 19 , 20 , 27 ] , and to ensure “information-richness [ 15 ]. An iterative sampling approach is advised, in which data collection (e.g. five interviews) is followed by data analysis, followed by more data collection to find variants that are lacking in the current sample. This process continues until no new (relevant) information can be found and further sampling becomes redundant – which is called saturation [ 1 , 15 ] . In other words: qualitative data collection finds its end point not a priori , but when the research team determines that saturation has been reached [ 29 , 30 ].

This is also the reason why most qualitative studies use deliberate instead of random sampling strategies. This is generally referred to as “ purposive sampling” , in which researchers pre-define which types of participants or cases they need to include so as to cover all variations that are expected to be of relevance, based on the literature, previous experience or theory (i.e. theoretical sampling) [ 14 , 20 ]. Other types of purposive sampling include (but are not limited to) maximum variation sampling, critical case sampling or extreme or deviant case sampling [ 2 ]. In the above EVT example, a purposive sample could include all relevant professional groups and/or all relevant stakeholders (patients, relatives) and/or all relevant times of observation (day, night and weekend shift).

Assessors of qualitative research should check whether the considerations underlying the sampling strategy were sound and whether or how researchers tried to adapt and improve their strategies in stepwise or cyclical approaches between data collection and analysis to achieve saturation [ 14 ].

Good qualitative research is iterative in nature, i.e. it goes back and forth between data collection and analysis, revising and improving the approach where necessary. One example of this are pilot interviews, where different aspects of the interview (especially the interview guide, but also, for example, the site of the interview or whether the interview can be audio-recorded) are tested with a small number of respondents, evaluated and revised [ 19 ]. In doing so, the interviewer learns which wording or types of questions work best, or which is the best length of an interview with patients who have trouble concentrating for an extended time. Of course, the same reasoning applies to observations or focus groups which can also be piloted.

Ideally, coding should be performed by at least two researchers, especially at the beginning of the coding process when a common approach must be defined, including the establishment of a useful coding list (or tree), and when a common meaning of individual codes must be established [ 23 ]. An initial sub-set or all transcripts can be coded independently by the coders and then compared and consolidated after regular discussions in the research team. This is to make sure that codes are applied consistently to the research data.

Member checking

Member checking, also called respondent validation , refers to the practice of checking back with study respondents to see if the research is in line with their views [ 14 , 27 ]. This can happen after data collection or analysis or when first results are available [ 23 ]. For example, interviewees can be provided with (summaries of) their transcripts and asked whether they believe this to be a complete representation of their views or whether they would like to clarify or elaborate on their responses [ 17 ]. Respondents’ feedback on these issues then becomes part of the data collection and analysis [ 27 ].

Stakeholder involvement

In those niches where qualitative approaches have been able to evolve and grow, a new trend has seen the inclusion of patients and their representatives not only as study participants (i.e. “members”, see above) but as consultants to and active participants in the broader research process [ 31 , 32 , 33 ]. The underlying assumption is that patients and other stakeholders hold unique perspectives and experiences that add value beyond their own single story, making the research more relevant and beneficial to researchers, study participants and (future) patients alike [ 34 , 35 ]. Using the example of patients on or nearing dialysis, a recent scoping review found that 80% of clinical research did not address the top 10 research priorities identified by patients and caregivers [ 32 , 36 ]. In this sense, the involvement of the relevant stakeholders, especially patients and relatives, is increasingly being seen as a quality indicator in and of itself.

How not to assess qualitative research

The above overview does not include certain items that are routine in assessments of quantitative research. What follows is a non-exhaustive, non-representative, experience-based list of the quantitative criteria often applied to the assessment of qualitative research, as well as an explanation of the limited usefulness of these endeavours.

Protocol adherence

Given the openness and flexibility of qualitative research, it should not be assessed by how well it adheres to pre-determined and fixed strategies – in other words: its rigidity. Instead, the assessor should look for signs of adaptation and refinement based on lessons learned from earlier steps in the research process.

Sample size

For the reasons explained above, qualitative research does not require specific sample sizes, nor does it require that the sample size be determined a priori [ 1 , 14 , 27 , 37 , 38 , 39 ]. Sample size can only be a useful quality indicator when related to the research purpose, the chosen methodology and the composition of the sample, i.e. who was included and why.

Randomisation

While some authors argue that randomisation can be used in qualitative research, this is not commonly the case, as neither its feasibility nor its necessity or usefulness has been convincingly established for qualitative research [ 13 , 27 ]. Relevant disadvantages include the negative impact of a too large sample size as well as the possibility (or probability) of selecting “ quiet, uncooperative or inarticulate individuals ” [ 17 ]. Qualitative studies do not use control groups, either.

Interrater reliability, variability and other “objectivity checks”

The concept of “interrater reliability” is sometimes used in qualitative research to assess to which extent the coding approach overlaps between the two co-coders. However, it is not clear what this measure tells us about the quality of the analysis [ 23 ]. This means that these scores can be included in qualitative research reports, preferably with some additional information on what the score means for the analysis, but it is not a requirement. Relatedly, it is not relevant for the quality or “objectivity” of qualitative research to separate those who recruited the study participants and collected and analysed the data. Experiences even show that it might be better to have the same person or team perform all of these tasks [ 20 ]. First, when researchers introduce themselves during recruitment this can enhance trust when the interview takes place days or weeks later with the same researcher. Second, when the audio-recording is transcribed for analysis, the researcher conducting the interviews will usually remember the interviewee and the specific interview situation during data analysis. This might be helpful in providing additional context information for interpretation of data, e.g. on whether something might have been meant as a joke [ 18 ].

Not being quantitative research

Being qualitative research instead of quantitative research should not be used as an assessment criterion if it is used irrespectively of the research problem at hand. Similarly, qualitative research should not be required to be combined with quantitative research per se – unless mixed methods research is judged as inherently better than single-method research. In this case, the same criterion should be applied for quantitative studies without a qualitative component.

The main take-away points of this paper are summarised in Table 1 . We aimed to show that, if conducted well, qualitative research can answer specific research questions that cannot to be adequately answered using (only) quantitative designs. Seeing qualitative and quantitative methods as equal will help us become more aware and critical of the “fit” between the research problem and our chosen methods: I can conduct an RCT to determine the reasons for transportation delays of acute stroke patients – but should I? It also provides us with a greater range of tools to tackle a greater range of research problems more appropriately and successfully, filling in the blind spots on one half of the methodological spectrum to better address the whole complexity of neurological research and practice.

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Abbreviations

Endovascular treatment

Randomised Controlled Trial

Standard Operating Procedure

Standards for Reporting Qualitative Research

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Busetto, L., Wick, W. & Gumbinger, C. How to use and assess qualitative research methods. Neurol. Res. Pract. 2 , 14 (2020). https://doi.org/10.1186/s42466-020-00059-z

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  • What Is Qualitative Research? | Methods & Examples

What Is Qualitative Research? | Methods & Examples

Published on June 19, 2020 by Pritha Bhandari . Revised on June 22, 2023.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research.

Qualitative research is the opposite of quantitative research , which involves collecting and analyzing numerical data for statistical analysis.

Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

  • How does social media shape body image in teenagers?
  • How do children and adults interpret healthy eating in the UK?
  • What factors influence employee retention in a large organization?
  • How is anxiety experienced around the world?
  • How can teachers integrate social issues into science curriculums?

Table of contents

Approaches to qualitative research, qualitative research methods, qualitative data analysis, advantages of qualitative research, disadvantages of qualitative research, other interesting articles, frequently asked questions about qualitative research.

Qualitative research is used to understand how people experience the world. While there are many approaches to qualitative research, they tend to be flexible and focus on retaining rich meaning when interpreting data.

Common approaches include grounded theory, ethnography , action research , phenomenological research, and narrative research. They share some similarities, but emphasize different aims and perspectives.

Note that qualitative research is at risk for certain research biases including the Hawthorne effect , observer bias , recall bias , and social desirability bias . While not always totally avoidable, awareness of potential biases as you collect and analyze your data can prevent them from impacting your work too much.

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Each of the research approaches involve using one or more data collection methods . These are some of the most common qualitative methods:

  • Observations: recording what you have seen, heard, or encountered in detailed field notes.
  • Interviews:  personally asking people questions in one-on-one conversations.
  • Focus groups: asking questions and generating discussion among a group of people.
  • Surveys : distributing questionnaires with open-ended questions.
  • Secondary research: collecting existing data in the form of texts, images, audio or video recordings, etc.
  • You take field notes with observations and reflect on your own experiences of the company culture.
  • You distribute open-ended surveys to employees across all the company’s offices by email to find out if the culture varies across locations.
  • You conduct in-depth interviews with employees in your office to learn about their experiences and perspectives in greater detail.

Qualitative researchers often consider themselves “instruments” in research because all observations, interpretations and analyses are filtered through their own personal lens.

For this reason, when writing up your methodology for qualitative research, it’s important to reflect on your approach and to thoroughly explain the choices you made in collecting and analyzing the data.

Qualitative data can take the form of texts, photos, videos and audio. For example, you might be working with interview transcripts, survey responses, fieldnotes, or recordings from natural settings.

Most types of qualitative data analysis share the same five steps:

  • Prepare and organize your data. This may mean transcribing interviews or typing up fieldnotes.
  • Review and explore your data. Examine the data for patterns or repeated ideas that emerge.
  • Develop a data coding system. Based on your initial ideas, establish a set of codes that you can apply to categorize your data.
  • Assign codes to the data. For example, in qualitative survey analysis, this may mean going through each participant’s responses and tagging them with codes in a spreadsheet. As you go through your data, you can create new codes to add to your system if necessary.
  • Identify recurring themes. Link codes together into cohesive, overarching themes.

There are several specific approaches to analyzing qualitative data. Although these methods share similar processes, they emphasize different concepts.

Qualitative research often tries to preserve the voice and perspective of participants and can be adjusted as new research questions arise. Qualitative research is good for:

  • Flexibility

The data collection and analysis process can be adapted as new ideas or patterns emerge. They are not rigidly decided beforehand.

  • Natural settings

Data collection occurs in real-world contexts or in naturalistic ways.

  • Meaningful insights

Detailed descriptions of people’s experiences, feelings and perceptions can be used in designing, testing or improving systems or products.

  • Generation of new ideas

Open-ended responses mean that researchers can uncover novel problems or opportunities that they wouldn’t have thought of otherwise.

Researchers must consider practical and theoretical limitations in analyzing and interpreting their data. Qualitative research suffers from:

  • Unreliability

The real-world setting often makes qualitative research unreliable because of uncontrolled factors that affect the data.

  • Subjectivity

Due to the researcher’s primary role in analyzing and interpreting data, qualitative research cannot be replicated . The researcher decides what is important and what is irrelevant in data analysis, so interpretations of the same data can vary greatly.

  • Limited generalizability

Small samples are often used to gather detailed data about specific contexts. Despite rigorous analysis procedures, it is difficult to draw generalizable conclusions because the data may be biased and unrepresentative of the wider population .

  • Labor-intensive

Although software can be used to manage and record large amounts of text, data analysis often has to be checked or performed manually.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

  • Chi square goodness of fit test
  • Degrees of freedom
  • Null hypothesis
  • Discourse analysis
  • Control groups
  • Mixed methods research
  • Non-probability sampling
  • Quantitative research
  • Inclusion and exclusion criteria

Research bias

  • Rosenthal effect
  • Implicit bias
  • Cognitive bias
  • Selection bias
  • Negativity bias
  • Status quo bias

Quantitative research deals with numbers and statistics, while qualitative research deals with words and meanings.

Quantitative methods allow you to systematically measure variables and test hypotheses . Qualitative methods allow you to explore concepts and experiences in more detail.

There are five common approaches to qualitative research :

  • Grounded theory involves collecting data in order to develop new theories.
  • Ethnography involves immersing yourself in a group or organization to understand its culture.
  • Narrative research involves interpreting stories to understand how people make sense of their experiences and perceptions.
  • Phenomenological research involves investigating phenomena through people’s lived experiences.
  • Action research links theory and practice in several cycles to drive innovative changes.

Data collection is the systematic process by which observations or measurements are gathered in research. It is used in many different contexts by academics, governments, businesses, and other organizations.

There are various approaches to qualitative data analysis , but they all share five steps in common:

  • Prepare and organize your data.
  • Review and explore your data.
  • Develop a data coding system.
  • Assign codes to the data.
  • Identify recurring themes.

The specifics of each step depend on the focus of the analysis. Some common approaches include textual analysis , thematic analysis , and discourse analysis .

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Qualitative Research Design: Start

Qualitative Research Design

qualitative research articles

What is Qualitative research design?

Qualitative research is a type of research that explores and provides deeper insights into real-world problems. Instead of collecting numerical data points or intervening or introducing treatments just like in quantitative research, qualitative research helps generate hypotheses as well as further investigate and understand quantitative data. Qualitative research gathers participants' experiences, perceptions, and behavior. It answers the hows and whys instead of how many or how much . It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data.

Qualitative research involves collecting and analyzing non-numerical data (e.g., text, video, or audio) to understand concepts, opinions, or experiences. It can be used to gather in-depth insights into a problem or generate new ideas for research. Qualitative research is the opposite of quantitative research, which involves collecting and analyzing numerical data for statistical analysis. Qualitative research is commonly used in the humanities and social sciences, in subjects such as anthropology, sociology, education, health sciences, history, etc.

While qualitative and quantitative approaches are different, they are not necessarily opposites, and they are certainly not mutually exclusive. For instance, qualitative research can help expand and deepen understanding of data or results obtained from quantitative analysis. For example, say a quantitative analysis has determined that there is a correlation between length of stay and level of patient satisfaction, but why does this correlation exist? This dual-focus scenario shows one way in which qualitative and quantitative research could be integrated together.

Research Paradigms 

  • Positivist versus Post-Positivist
  • Social Constructivist (this paradigm/ideology mostly birth qualitative studies)

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CMU Libraries is committed to helping members of our community become data experts. To that end, CMU is offering public facing workshops that discuss Qualitative Research, Coding, and Community Engagement best practices.

The following workshops are a part of a broader series on using data. Please follow the links to register for the events. 

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Join us for an event to improve, build on and expand the connections between Carnegie Mellon University resources and the Pittsburgh community. CMU resources such as the Libraries and Sustainability Initiative can be leveraged by users not affiliated with the university, but barriers can prevent them from fully engaging.

The conversation features representatives from CMU departments and local organizations about the community engagement efforts currently underway at CMU and opportunities to improve upon them. Speakers will highlight current and ongoing projects and share resources to support future collaboration.

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Taiwo Lasisi, CLIR Postdoctoral Fellow in Community Data Literacy,  Carnegie Mellon University Libraries

Emma Slayton, Data Curation, Visualization, & GIS Specialist,  Carnegie Mellon University Libraries

Nicky Agate , Associate Dean for Academic Engagement, Carnegie Mellon University Libraries

Chelsea Cohen , The University’s Executive fellow for community engagement, Carnegie Mellon University

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Qualitative Research Methods

What are Qualitative Research methods?

Qualitative research adopts numerous methods or techniques including interviews, focus groups, and observation. Interviews may be unstructured, with open-ended questions on a topic and the interviewer adapts to the responses. Structured interviews have a predetermined number of questions that every participant is asked. It is usually one-on-one and is appropriate for sensitive topics or topics needing an in-depth exploration. Focus groups are often held with 8-12 target participants and are used when group dynamics and collective views on a topic are desired. Researchers can be participant observers to share the experiences of the subject or non-participant or detached observers.

What constitutes a good research question? Does the question drive research design choices?

According to Doody and Bailey (2014);

 We can only develop a good research question by consulting relevant literature, colleagues, and supervisors experienced in the area of research. (inductive interactions).

Helps to have a directed research aim and objective.

Researchers should not be “ research trendy” and have enough evidence. This is why research objectives are important. It helps to take time, and resources into consideration.

Research questions can be developed from theoretical knowledge, previous research or experience, or a practical need at work (Parahoo 2014). They have numerous roles, such as identifying the importance of the research and providing clarity of purpose for the research, in terms of what the research intends to achieve in the end.

Qualitative Research Questions

What constitutes a good Qualitative research question?

A good qualitative question answers the hows and whys instead of how many or how much. It could be structured as a stand-alone study, purely relying on qualitative data or it could be part of mixed-methods research that combines qualitative and quantitative data. Qualitative research gathers participants' experiences, perceptions and behavior.

Examples of good Qualitative Research Questions:

What are people's thoughts on the new library? 

How does it feel to be a first-generation student attending college?

Difference example (between Qualitative and Quantitative research questions):

How many college students signed up for the new semester? (Quan) 

How do college students feel about the new semester? What are their experiences so far? (Qual)

  • Qualitative Research Design Workshop Powerpoint

Foley G, Timonen V. Using Grounded Theory Method to Capture and Analyze Health Care Experiences. Health Serv Res. 2015 Aug;50(4):1195-210. [ PMC free article: PMC4545354 ] [ PubMed: 25523315 ]

Devers KJ. How will we know "good" qualitative research when we see it? Beginning the dialogue in health services research. Health Serv Res. 1999 Dec;34(5 Pt 2):1153-88. [ PMC free article: PMC1089058 ] [ PubMed: 10591278 ]

Huston P, Rowan M. Qualitative studies. Their role in medical research. Can Fam Physician. 1998 Nov;44:2453-8. [ PMC free article: PMC2277956 ] [ PubMed: 9839063 ]

Corner EJ, Murray EJ, Brett SJ. Qualitative, grounded theory exploration of patients' experience of early mobilisation, rehabilitation and recovery after critical illness. BMJ Open. 2019 Feb 24;9(2):e026348. [ PMC free article: PMC6443050 ] [ PubMed: 30804034 ]

Moser A, Korstjens I. Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. Eur J Gen Pract. 2018 Dec;24(1):9-18. [ PMC free article: PMC5774281 ] [ PubMed: 29199486 ]

Houghton C, Murphy K, Meehan B, Thomas J, Brooker D, Casey D. From screening to synthesis: using nvivo to enhance transparency in qualitative evidence synthesis. J Clin Nurs. 2017 Mar;26(5-6):873-881. [ PubMed: 27324875 ]

Soratto J, Pires DEP, Friese S. Thematic content analysis using ATLAS.ti software: Potentialities for researchs in health. Rev Bras Enferm. 2020;73(3):e20190250. [ PubMed: 32321144 ]

Zamawe FC. The Implication of Using NVivo Software in Qualitative Data Analysis: Evidence-Based Reflections. Malawi Med J. 2015 Mar;27(1):13-5. [ PMC free article: PMC4478399 ] [ PubMed: 26137192 ]

Korstjens I, Moser A. Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. Eur J Gen Pract. 2018 Dec;24(1):120-124. [ PMC free article: PMC8816392 ] [ PubMed: 29202616 ]

Saldaña, J. (2021). The coding manual for qualitative researchers. The coding manual for qualitative researchers, 1-440.

O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014 Sep;89(9):1245-51. [ PubMed: 24979285 ]

Palermo C, King O, Brock T, Brown T, Crampton P, Hall H, Macaulay J, Morphet J, Mundy M, Oliaro L, Paynter S, Williams B, Wright C, E Rees C. Setting priorities for health education research: A mixed methods study. Med Teach. 2019 Sep;41(9):1029-1038. [ PubMed: 31141390 ]

  • Last Updated: Feb 14, 2024 4:25 PM
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  • Open access
  • Published: 12 February 2024

Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study

  • Daniel Romeu   ORCID: orcid.org/0000-0002-2417-0202 1 , 2 ,
  • Elspeth Guthrie   ORCID: orcid.org/0000-0002-5834-6616 1 ,
  • Sonia Saraiva   ORCID: orcid.org/0000-0002-2305-9246 1 ,
  • Carolyn Czoski-Murray   ORCID: orcid.org/0000-0001-7742-2883 1 ,
  • Jenny Hewison   ORCID: orcid.org/0000-0003-3026-3250 1 &
  • Allan House   ORCID: orcid.org/0000-0001-8721-8026 1  

BMC Health Services Research volume  24 , Article number:  191 ( 2024 ) Cite this article

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Metrics details

Recent investment in UK liaison psychiatry services has focused on expanding provision for acute and emergency referrals. Little is known about the experiences of users and providers of these services. The aim of this study was to explore the experiences of users of acute liaison mental health services (LMHS) and those of NHS staff working within LMHS or referring to LMHS. A secondary aim was to explore the potential impact of a one-hour service access target on service delivery.

Cross-sectional qualitative study. Individual interviews were audio-recorded, transcribed verbatim and interpreted using framework analysis.

Service users reported mixed experiences of LMHS, with some reporting positive experiences and some reporting poor care. Most service users described the emergency department (ED) environment as extremely stressful and wished to be seen as quickly as possible. Staff described positive benefits of the one-hour access target but identified unintended consequences and trade-offs that affected other parts of the liaison service.

Conclusions

The assessment and treatment of people who attend ED with mental health problems needs to improve and particular attention should be given to the stressful nature of the ED environment for those who are extremely agitated or distressed.

Peer Review reports

The number of people attending emergency departments (EDs) in England has continued to rise, aside from the COVID-19 period. In 2019/20, there were 25.0 million ED attendances compared to 21.5 million in 2011/12 1 . In April 2022, waiting time performance in EDs was the worst recorded in modern data collections [ 1 ], and people with mental health problems had to wait substantially longer than those with physical health problems. Although mental health presentations decreased during lockdown, there was a bounce back post-lockdown with even greater numbers attending ED than before [ 2 ].

There are relatively few studies of people’s experiences of liaison mental health services (LMHS) in the UK. A recent internet survey of respondents’ experiences of LMHS in England showed that only 31% of service users found their contact with such services helpful [ 3 ]. Latent class analysis identified three types of experience; those who had a positive experience, those who reported a negative experience and those who were non-committal. Suggestions for improvement included the provision of a 24/7 service, reduced waiting times for assessment, and clearer communication about treatment or care post-assessment.

Prior studies of user satisfaction of LMHS in the UK have also been mixed [ 4 ]. One previous study which involved in-depth qualitative interviews with service users found that people complained about long waiting times before being able to access liaison services [ 5 ]. Some service users reported good experiences characterised by close collaboration between the service user and liaison practitioner whilst others described po or experiences.

In contrast with the UK, studies from Australia have reported positive service user experiences of LMHS with high levels of service user satisfaction [ 6 , 7 , 8 ]. In one study, service users reported timely access to being seen by a liaison practitioner and reported feeling listened to, understood and helped in a positive fashion, with an emphasis on problem solution [ 6 ].

All 170 hospitals in England with an ED now have at least a rudimentary LMHS [ 9 ]. These services have undergone substantial growth in the last seven years following significant investment from NHS England [ 10 ]. There has been particular expansion in acute services, and a “Core-24” service model has been developed, with staffing ratios based upon hospital size in terms of bed numbers [ 11 ]. These Core-24 teams usually consist of at least one liaison psychiatrist and several liaison mental health nurses. They focus on emergency work, providing 24-hour cover for EDs and acute ward referrals, with an emphasis on one-off assessments followed by signposting.

These new developments have been accompanied by rigorous performance targets for response times and throughput. In 2016, NHS guidance stated that a person experiencing a mental health crisis should receive a response from a LMHS within a maximum of 1 h of receipt of referral, and within 4 h the person should have received: “ a full biopsychosocial assessment if appropriate, and have an urgent and emergency mental health care plan in place, and as a minimum, be en route to their next location if geographically different, or have been accepted and scheduled for follow-up care by a responding service, or have been discharged because the crisis has resolved” [ 11 ]. Further review of access standards for mental health services in 2021 maintained the 1-hour target [ 9 ], although waiting time targets for all patients attending EDs are under review due to consistent and increasing failures to meet them.

While many hospitals have benefitted from the introduction of Core-24, especially where there were no or only rudimentary services previously, other established liaison services have had to change or modify their ways of working to meet targets. In addition to acute cover, these established services previously offered lower volume, higher intensity work involving the assessment, treatment and co-management of patients with complex physical and mental health problems seen in either inpatient or outpatient settings.

We previously completed interviews with 73 NHS staff from 11 hospital trusts in England who were either LMHS staff or worked closely with them and found that interviewees most valued being able to spend time with patients to carry out therapeutic interventions [ 12 ]. Some staff provided continued treatment for patients admitted to acute hospitals over several weeks. For example, in one service mental health nurses regularly visiting older adult patients or those on stroke wards to provide encouragement with eating and rehabilitation, both vital components of ensuring recovery. Teams with psychologists, therapists or mental health nurses trained in specific interventions (like cognitive behavioural therapy) offered brief interventions while the patient was admitted to an acute hospital bed, or a follow-up appointment after discharge. Staff reported problems with continuity of care across the secondary-primary interface; a lack of mental health resources in primary care to support discharge; a lack of shared information systems; a disproportionate length of time spent recording information instead of face-to-face patient contact; and a lack of a shared vision of care. Similar issues were identified across different liaison service types.

The aim of the present study was to better understand the experiences of users and providers of LMHS, and to explore hospital staff’s experiences of the changes brought about by the NHS England’s investment in Core-24 and any impact on patient care. We were particularly interested in improving our understanding of the mechanisms and trade-offs involved in relation to meeting one key performance target, the one-hour response time set by NHS England for LMHS. Recent programme theory suggests that the imposition of such fixed targets may have unintended consequences for liaison services and other parts of the health care system [ 13 ].

This work formed part of the first phase of a programme funded through the NIHR Health Services and Delivery Research scheme to evaluate the cost-effectiveness and efficiency of different configurations of liaison psychiatry services in England (LP-MAESTRO) [ 14 ]. The Consolidating Criteria for Reporting Qualitative Research (COREQ) guidelines [ 15 ] have been followed.

This was a cross-sectional qualitative study with service users of hospital-based LMHS and hospital staff with either experience of working in, or working closely with, LMHS.

Setting and sample

Service users were recruited from two Northern cities in England. We aimed to recruit 8–10 service user participants and developed a purposive sampling frame to ensure maximum variation. Potential participants were approached by either LMHS staff to determine their interest, or by local service user organisations who were invited to identify participants for the project through their own contacts. Once consent to contact had been provided by the service users, they were contacted directly by a member of the research team, who explained the study and provided a study information sheet. The potential participant was given at least 48 h to decide whether to participate. All participants provided written informed consent and there were no dropouts. No relationship was established with participants prior to study commencement. Participants were not informed of any of the interviewers’ personal goals for conducting the research.

Hospital staff were recruited from two hospitals in Northern England, both with EDs and within the same city. A maximum-divergence sampling frame was developed to maximise diversity according to professional background, sub-specialism within the LMHS, clinical or managerial focus and whether liaison team member or referrer to the service. Overall, we planned to recruit 8–10 staff participants. All staff participants provided written informed consent and there were no dropouts.

Data collection

Service users.

Nine service users were individually interviewed using a semi-structured topic guide. The service user topic guide was developed for this study (LP MAESTRO) and not published elsewhere (see Additional file 1 ). It consisted of a list of key topic areas with open-ended questions and additional prompts covering the following areas: introductory questions identifying the contact the participant had had with acute care; experiences of the acute care received from acute hospital staff; accounts of care received from LMHS staff; and views on desirable changes and ways to achieve them. They were not asked specifically about Core-24 developments, as it was unlikely that they would be familiar with such policy and staffing changes. However, staffing and waiting times were included as part of the topic guide.

Hospital Staff

Eight hospital staff were individually interviewed using a semi-structured topic guide. The hospital staff topic guide was adapted from an earlier topic guide used in the LP-MAESTRO study in relation to a previous investigation of liaison psychiatry and hospital staff experiences of liaison services [ 12 ]. The adapted topic guide, which focuses primarily on staff experiences of CORE-24 is provided in Additional file 2 . The following key topic areas were covered: introductory questions about the staff member’s work history and the nature of their involvement with LMHS; experiences of LMHS prior to introduction of Core-24; description of any changes resulting from Core-24; impact of these changes on the service; impact on patient care; and views on how the service could be improved.

Interviews lasted 30–90 min and took place via telephone between September 2017 and February 2019. Participant interviews were conducted first, followed by interviews with hospital staff. With permission all interviews were audio-recorded and transcribed verbatim. There were no repeat interviews. Transcripts were not returned to participants for comment or correction. Only the interviewer and participant were present at each interview. No field notes were recorded.

Interviews were conducted by three researchers, all from the Leeds Institute of Health Sciences and qualified by experience and training (CCG, SS, EG). None were involved in the delivery of acute LMHS at the time of the study. EG is a female Professor of Psychological Medicine and Consultant Psychiatrist. CCM is a female Senior Research Fellow and SS is a female Research Fellow. EG had previously worked in an acute liaison mental health team and was generally supportive of the Core-24 developments prior to the study. Neither SS nor CCM had a priori views or identified biases. The form and content of the topic guides were developed in collaboration with people with personal experience of mental health problems and accessing LMHS.

Data analysis

The semi-structured interviews were interpreted independently by DR and EG using framework analysis [ 16 ]. This is a qualitative method that is useful in research that has specific questions, a limited time frame and a pre-determined sample; it is therefore well-suited to applied policy research. First, DR and EG independently read all transcripts with the study’s aim in mind. Each then independently reviewed all transcripts line by line identifying relevant experiences, opinions, descriptions of incidents and emotions (codes). DR collated codes into a draft theoretical framework which was refined through discussion with EG. It became apparent to base several framework categories around the key areas of interest in the interview schedule as we wanted to be open to issues arising from the data. DR then matched the data to the provisional framework. Each example was independently included under one or more theme in the thematic chart by DR and EG who then met to resolve any disparities. In the final stage, findings were reviewed by AH. Relevant supporting quotations were then extracted from interview transcripts to illustrate each theme and sub-theme. Data from service users and staff were analysed separately but are presented together if relevant to the theme or sub-theme. Participants were not asked to provide feedback on the findings.

Sample characteristics

Seventeen in-depth interviews were conducted, nine with LMHS users and eight with healthcare professionals. Service user participants consisted of 3 men and 6 women with varying age ranges (Table  1 ). Presenting problems included self-harm, psychosis, mania, long-term physical health problems and medically unexplained symptoms. The interviewed professionals were mental health liaison nurses ( n  = 3), consultant liaison psychiatrists ( n  = 2), general nurses ( n  = 2) and one consultant in emergency medicine.

Main findings

Participants discussed a range of topics surrounding the provision and experience of mental healthcare in general hospitals. They illustrated the complexity involved in meeting mental health needs in this setting. Below we outline our findings in terms of themes and sub-themes that emerged from the interviews; the four themes and their constituent subthemes are summarised in Table  2 . The staff topic guide included specific questions about Core-24 that were not included in the service users’ topic guide, so most of the sub-themes around the Core-24 service standard are only relevant to staff participants.

Theme one: the emergency department (ED)

Healthcare professionals and service users discussed their views of the ED as a site for mental healthcare provision. The content of their discourse comprised the sub-themes of ED staff, physical environment, appropriateness for mental health problems and desired characteristics.

Service users recounted highly variable experiences of ED staff when seeking help for their mental health problems. Some were described as kind and compassionate people who acknowledged distress and evoked feelings of validation:

“ They recognised I wasn’t putting things on, that I did feel acutely suicidal as I was saying ” – Participant 1.

Others disclosed negative views of ED staff, describing them as unpleasant and harsh. Three participants reported that ED staff withheld treatment that they thought was needed. Others reported that staff did not allow the service user to speak and failed to provide any guidance or support on discharge.

“The GP referred me to A&E and when I arrived there, they were very very harsh” – Participant 6.

LMHS professionals generally had negative perceptions of ED staff, reporting that they had poor psychiatric knowledge and skills. Several felt that ED staff did not appreciate the role of LMHS and frequently made inappropriate referrals. Some suggested that ED staff had little interest in mental health problems:

“I think sometimes they don’t ask more questions about mental health, and I don’t know if that is because they don’t feel confident to, or they just don’t want to” – Participant 13.

Physical environment

The ED environment was discussed exclusively by service users, and their opinions were overwhelmingly negative. Common issues were that the assessment room was uncomfortable and small:

“You’re brought into this really small room with no windows, it was tiny, it was also not necessarily painted, it was very scruffy ” – Participant 5.

A lack of provision of refreshments contributed to a sense of discomfort. The privacy of the assessment environment varied; two individuals reported that they were assessed in a private space, and one was not:

“In the department with just a curtain pulled around, so it wasn’t very private” – Participant 1.

Appropriateness for mental health problems

Both service users and providers questioned the appropriateness of the ED for people with mental health needs. No participants felt that the ED was an appropriate place for these needs.

“A lot of them are quite vulnerable, and more at risk of accidental self-harm or sort of vulnerable from other people in the department and it’s A&E isn’t it, I wouldn’t it consider a very nice environment for people that are experiencing psychosis” – Participant 13.

Service users described their experiences of seeking care in the ED as anxiety-provoking and lonely. They acknowledged that attending the department was an undesirable last resort, only done when other services and professionals could not be accessed in the community.

“It’s not the best solution by any stretch of the imagination but, but it’s the only place that’s available” – Participant 8.

Desired characteristics

Participants suggested ways that the ED could be improved to better care for those with mental health needs. These included a more comfortable environment, the option to wait outside, better communication of next steps and knowledge of community-based support. One participant suggested the provision of company while awaiting input from the mental health team.

“I don’t know what else they could do apart from have somebody sit with you all the time until the psychiatrist came or somebody to assess you” – Participant 7.

Liaison practitioners also felt that the ED could be improved by providing more staff training in mental health assessments and improving referrals to the LMHS. This could reduce the volume of referrals and facilitate referral triage while reducing wait times for service users.

“If you upskill the ED people to even basic then liaison psychiatry should be able to turn down referrals… And we have to remember in the middle of all of this is a patient” – Participant 15.

Theme two: Liaison mental health services (LMHS)

The second theme refers to participants’ views and experiences of liaison mental health services (LMHS). There are three sub-themes: experiences of LMHS, barriers to contact and desired characteristics.

Service users described variable experiences of the help they received from LMHS. Contact with LMHS helped some individuals to feel more comfortable and to understand the next steps. Some described a therapeutic benefit of talking in depth about their issues:

“It helps me mental health, being able to talk about it and stuff” – Participant 3.

Others voiced that LMHS were either unhelpful or contributed to them feeling worse. This was related to the feeling of not being listened to and the perception that no tangible help or support was offered.

“ I’ve not got time for them as they do nothing for me” – Participant 9.

Some service users held the view that LMHS complete little more than a “box-ticking” exercise that offers little benefit to the service user. This was echoed by one of the physical healthcare professionals.

Common problems were that the professionals seemed rushed and incompetent. Three participants shared the view that LMHS staff were dismissive or disinterested. This led them to feel guilty and as though they had wasted the professional’s time.

“Sometimes the mental health staff can be very dismissive and treat me like I’ve just wasted everybody’s time, and I should have just looked after myself at home” – Participant 8.

Others described LMHS staff in a more positive light, reflecting that they allowed them to speak freely while listening carefully and acknowledging their needs. In some interviews, LMHS staff were described as caring and comforting. One participant felt that LMHS staff are underappreciated:

“I know with my experiences with liaison psychiatry that they do a lot more than people may think” – Participant 4.

Generally, interviewed professionals were complimentary towards LMHS staff, describing them as hard-working, knowledgeable, experienced, accessible, and committed to high-quality patient care. Participants had conflicting views on whether LMHS staff have a good relationship with the ward teams and whether they meet their expectations, although this was often attributed to a rise in demand for the service.

Barriers to contact

Participants discussed barriers to accessing LMHS. Some service users recounted how input from LMHS was postponed or withheld because they were under the care of a community mental health team. This sometimes resulted in interactions with a “diversion team”, which was described as a frustrating, obstructive experience.

“You just can’t get past diversion because they’ve been put in place to stop people like me who are known to the system… They’re basically there to go, ‘there, there, you’re ok, you go home and speak to your care coordinator tomorrow.’” – Participant 8.

Staff felt that significant barriers to contact with LMHS included insufficient staffing levels, particularly out of hours, and a seemingly excessive amount of time completing documentation.

“The [LMHS] team spend a long time writing things up and reporting… If we do make a referral for later in the evening or overnight, I don’t work nights, but they’re often told, ‘oh we can’t come and see the patient because we’re writing up our reports!’” – Participant 12.

Service users outlined factors that would improve their experience of receiving care from LMHS. Several participants described dissatisfaction with being discharged without a clear treatment plan and called for the provision of aftercare and more information about third sector organisations.

“If someone’s self-harming or whatever they shouldn’t just be discharged. They need aftercare and everything. It should be in their care plan.” – Participant 2.

Some described desirable characteristics of LMHS staff, which included compassion, knowledge, and clearer communication of delays and anticipated next steps. Service users expressed a desire to be treated as an individual and to be listened to attentively.

“You need front-line staff who have the personal interactive skills to acknowledge, to offer comfort and explain what is going to happen, not front-line staff who make you more agitated or that they are confused” – Participant 5.

Other desirable characteristics of the service identified include universal service provision across the country, a switch of focus from medications to psychosocial interventions, and a separate service for those who do not meet the criteria for admission but who feel unsafe to return home. Some service users voiced support for an acute mental health service separate from the ED.

Theme three: core-24 service standard

This theme encapsulates views towards the Core-24 service standard and the subthemes are the 1-hour wait, perceived benefits, unintended consequences , and policymaker detachment.

1-hour wait

Although professionals acknowledged the importance of targets, many felt that the one-hour target was unattainable, particularly for those with complex presentations or substance issues. Some felt that it was inappropriate to assume that service users’ needs are constant throughout the day. There was a consensus that immediacy was prioritised over clinical importance, which manifests as brief introductions within the hour instead of careful, comprehensive assessments.

“It’s not about how quickly you are seen, it’s about the quality of the interaction and I think if you are having to respond to patients in an hour that can sometimes compromise the quality” – Participant 16.

In contrast, service users almost universally expressed a wish to receive contact from the LMHS as soon as possible, and even a one hour wait felt too long to wait if someone was very distressed.

“When you are thinking of taking your own life, an hour is a lifetime” – Participant 1.

Perceived benefits (staff only)

The most salient benefit reported by the healthcare professionals was investment in the LMHS. They described more financial investment into the service, and the creation of staff posts to expand the workforce, contributing to feelings of reassurance and comfort. Although participants acknowledged the associated challenges of training new staff, overall, this change was perceived as positive.

“The investment within the services has enabled us to, erm you know, to broaden out what we do” – Participant 17.

Generally, professionals explained that the service standard improved patient flow. They felt that one-hour reviews were conducive to faster discharges and the prevention of unnecessary hospital admissions. They also reported a greater focus on the service user experience and acknowledged the target as an opportunity to improve the service further.

“I think that’s been a huge positive for the team because it’s made them think, actually, okay, we need to do this. How are we going to do it in the best way possible to get the service users experience and the standard of care for them as best as we can?” – Participant 14.

Unintended consequences (staff only)

Professionals also reported numerous undesired sequelae to the Core-24 one hour target. The first was that the target acted as an incentive for people to use the ED for their mental health needs in the knowledge that they would be seen quickly. This contributed to a rise in the clinical workload for both ED and LMHS staff.

“It was an odd thing to do when you’re trying to decrease attendances, it’s like a bit of an incentive to [attend the ED]” – Participant 11.

Some explained that the target had a detrimental impact on servicing providing ward cover, as LMHS staff are diverted from wards to the ED for initial reviews for new presentations. This results in delays on the wards and subsequently prolongs admissions.

“They used to see people who were in the beds before the parvolex (a treatment following a paracetamol overdose) ended, but they’re just unable to do that now because of the amount of people in A&E to be seen” – Participant 10.

The target has also had ramifications on working hours, with some participants reporting that their shifts were extended from eight to twelve hours, resulting in more lone working and reduced staff morale. This was identified as the reason for some staff members deciding to leave their jobs.

Policymaker detachment (staff only)

Generally, professionals felt that Core-24 was implemented poorly by policymakers and commissioners who were disconnected from the service. They described that no attempts were made to seek the views of clinicians, and that it was delivered as a compulsory change.

“The way that this change was brought in was very top-down, there was very little engagement with the team” – Participant 16.

One professional reported that they were informed with little notice that older people would be included in the remit of LMHS following the standard, and they received no formal training for this. The disconnect between policymakers and clinicians resulted in resentment among staff.

Service users echoed this idea by suggesting that policymakers were detached from the views and priorities of those seeking care. Some mentioned that these should be incorporated into decisions about LMHS provision:

“I think that the service should get more involvement from the service user’s experience” – Participant 6.

Theme four: stigma of mental illness

The final theme describes the stigma associated with mental health problems. The subthemes were discrimination and the mental-physical dichotomy .

Discrimination

Service users commonly felt discriminated against for having mental health problems. They described being treated differently to those with physical health problems, with their issues not being taken as seriously. Some recalled being dismissed and feeling guilty for accessing services.

“If you’re physically ill that counts, it’s given a higher priority over mental illness” – Participant 4.

Professionals also acknowledged the discrimination against those with mental health problems in the general hospital setting. They commented that service users with mental health needs are generally perceived as problematic and unwanted in the ED.

“Patients with mental health difficulties in the emergency department are the difficult ones, the bad ones, the ones that upset the data, or the ones that don’t move out quick enough” – Participant 15.

The mental-physical dichotomy

This subtheme describes the clear delineation between physical and mental health in the context of healthcare services. Both professionals and service users commented that mental health needs are frequently neglected in physical healthcare settings. This is attributed to a perceived unwillingness to enquire about psychiatric symptoms and a tendency to ignore biopsychosocial determinants of health.

“If I was to mention mental state, your consultants turn their faces away from me” – Participant 9.
“The traditional method of dealing with a lack of liaison psychiatry in the general hospital is to ignore the problem and just pretend it’s not there, to not notice that the patient is sad, not notice that they are anxious, to blame the patient, to discharge them early, to not take care of the wider side of psychosis difficulties that have prompted this admission” – Participant 15.

Clinicians also perceived a divide between mental and physical healthcare professionals. Some LMHS staff felt that ED clinicians had poor psychiatric knowledge and skills, that they often made inappropriate referrals with minimal information, and that their service was not understood or appreciated.

“I don’t think mental health is respected within the A&E department as a proper profession” – Participant 13.

Final analysis

The final stage of analysis is summarised in Table  3 , which shows comparisons across the service user and staff groups whilst also reflecting the strength of the signals from the data (determined by the proportion of participants who voiced these opinions). It shows some striking differences in patterns but also several areas of agreement. The one-hour access target is seen differently by service users and staff whilst issues related to stigma are perceived as important by both groups.

How our results compare

There are relatively few qualitative studies of LMHS, so this study is an important addition to the field. The variable experiences of LMHS users in this study are similar to those described by Eales and colleagues [ 5 ] and consistent with the recently published online survey of LMHS users [ 3 ]; some people reported good treatment and care from LMHS, whilst others report poor care and an unhelpful experience. Despite the increased funding for LMHS in recent years, people’s experiences remain patchy and well below the satisfaction levels reported by users of services in Australia [ 7 , 17 , 18 , 19 ]. However, it is difficult to compare services between countries with different healthcare systems.

Most service users felt that the ED environment contributed to additional stress and was an inappropriate place for people with acute mental health problems. This is consistent with previous studies [ 20 , 21 ], which have highlighted the negative and stressful aspects of the ED for people with mental health issues and described the ED as overstimulating and lacking in comfort and privacy. This is set against a backdrop of a recent survey carried out by the Royal College of Psychiatrists which reported that more than three quarters of people referred to mental health services resort to using emergency services because their mental health deteriorates whilst waiting for an initial assessment [ 22 ].

Wait-time targets

Opinions about the appropriateness and helpfulness of the one-hour performance target for LMHS varied between service users and staff. Service users highlighted the importance of being seen as quickly as possible in ED, particularly because the environment was stressful, but also because they were in a heightened state of distress and needed urgent relief. Some staff, however, believed the one-hour target distorted clinical practice with performance taking precedence over clinical need. This resulted in many unintended consequences including encouraging an increase in mental health ED attendances and a detrimental effect on other parts of the liaison service.

These findings support a logic model we previously developed to explain the impact an increase in liaison mental health provision may have on specific target response times [ 13 ]. Increased staffing levels initially enable LMHS to see more service users within the designated response target time, but various tensions and trade-offs within the system become apparent over time. If more service users attend ED due to the quicker response time, coupled with long waits in the community, pressure on the system increases again. This pressure causes a tension between the balance of ED work and the needs of patients with severe mental health problems who are inpatients in the acute hospital. The focus on ED and meeting the response target may result in potential disruptions to the care of hospital inpatients with deleterious clinical consequences and increased length of hospital stays. The introduction of a response target inevitably leads to unintended consequences in other parts of the healthcare system; the balance of advantages and disadvantages of the target across the whole system needs to be considered.

Public stigma and discrimination against people with mental illness is not a new phenomenon and is still widespread in society [ 23 ]. A review of 42 studies of ED staff attitudes towards service users presenting with mental health problems, 14 of which were conducted in the UK, reported widespread perceived negativity, although positive experiences were also acknowledged [ 24 ]. The findings from our study suggests negative attitudes towards people with mental health problems are still problematic in the ED setting. A recent qualitative systematic review exploring stigma and discrimination experienced by mentally ill individuals seeking care for physical and mental health concerns suggests that stigma and discrimination significantly compromise the quality of healthcare relationships with services users [ 25 ].

What can be done?

The Royal College of Emergence Medicine has produced a useful toolkit for improving care of people with mental health problems whilst in the ED, which stresses that all people with either a physical or mental health problem should have access to ED staff that understand and can address their condition [ 21 ]. There is a clear driver from both the Royal College of Emergency Medicine and the Royal College of Psychiatrists to improve the care of people with mental health problems who attend ED. There has also been recognition of this problem by NHS England with funding in 2017–2018 of £18 million for 234 winter mental health schemes to help alleviate pressures in ED for people with mental health problems [ 26 ]. Most of the funding was allocated to mental health liaison schemes, community crisis resolution and discharge and step-down schemes. Although many individual schemes reported local positive benefits, there were no robust evaluations which would support national rollout of any of these schemes.

There is some evidence that small positive attitude changes towards people with mental illness can be achieved by specific stigma reduction interventions [ 27 ], although relatively few interventions have been evaluated in the ED. Most educational interventions have focused solely on knowledge acquisition for specific conditions such as substance misuse disorders [ 28 ]. However, the endemic nature of stigma towards mental illness suggests that multi-level changes are required at organisational and personal levels. The Lancet Commission on ending discrimination in mental health included a review of all forms of stigma and discrimination against people with mental health conditions in all settings and societies globally [ 23 ]. The authors made several recommendations including policy and societal changes and workplace changes. Of relevance to the ED setting, they recommend that all healthcare staff receive mandatory training on the needs and rights of people with mental conditions, co-delivered by people with lived experience of mental health issues.

The staffing recommendations for Core-24 LMHS were largely based upon the size of hospital and the knowledge that mental health issues account for 4% of ED attendances. However, recent work suggests a further 4% of ED attendances consist of people attending with a physical health problem but who also have significant mental health issues [ 2 ]. This suggests that current LMHS staffing levels need to be reviewed, as Core-24 guidance may have underestimated the workload demands on LMHS, and workload is better estimated by patient throughput than the size of the hospital in terms of bed numbers or the presumed percentage of people in ED who may require liaison services [ 29 ].

Strengths and limitations

This study has several strengths. First, we met our recruitment targets, although, recruitment of service users took longer than we anticipated. There are no patient organisations that represent liaison service users, so recruitment can be challenging. However, we achieved a wide diversity of service user participants in terms of demographic characteristics and clinical problem areas. The most common clinical problems seen by liaison services in England are co-morbid physical and mental health problems, self-harm and cognitive problems [ 29 ]. Participants with co-morbid physical and mental health problems were represented in our participant sample. However, service users with cognitive problems were excluded from this study due to the inability to provide informed consent to participate. Second, the staff participants came from a range of professional backgrounds, including those who worked within LMHS and those who referred to LMHS. Third, we were able to explore both service user and staff perspectives about an important aspect of current service provision – the one-hour access target.

There were several limitations to the study. First, our sample size was relatively small and service user participants were only recruited from two geographical areas, and hospital staff from only two hospitals. We required members of staff who had experience of LMHS both prior to and subsequent to the introduction of Core-24, which limited the number of staff who we could interview and were willing to participate in the study. This also limited our ability to interview to the point of saturation. A larger staff sample may have resulted in other themes emerging so the findings of this study cannot therefore be generalised to other services in England, although many of the findings do accord with previous work in this area. Second, as discussed above, we were unable to recruit people with cognitive problems, making findings less relevant to liaison services for older adults. Third, interviews with participants and staff were conducted before the COVID-19 pandemic and its impact upon healthcare delivery. There was a marked drop-off in ED attendances during lockdown and the many liaison ED services were moved to other parts of the hospital to minimise spread of infection. Although there has been a clear bounce back in ED attendances among people with mental health problems post-pandemic [ 2 ], it is unclear to what extent services and service users have changed.

This study provides compelling evidence that the assessment and treatment of people who attend ED with mental health problems needs to further improve. The negative staff attitudes described are unacceptable, services for aftercare following assessment are inadequate, and the immediate experience in ED is often negative.

Particular attention should also be given to the stressful nature of the ED environment for those who are agitated or distressed. It can be argued that the ED is not the most appropriate place for people with acute mental health needs, but at present, there is often no clear alternative. Diversion schemes are under development in some areas. However, there will always be a need for many people with mental health problems to attend ED, as people with mental health issues commonly also have physical health problems, which require investigation and management in parallel with their mental health difficulties. Whilst ED service users emphatically support the one-hour response target, the imposition of such targets can have unintended consequences on other parts of the liaison service which need to be balanced to ensure parity for LMHS users in ED and those admitted in the acute hospital as inpatients.

Availability of data and materials

Data from this study are not available due to the qualitative nature of the study.

Abbreviations

Liaison Mental Health Service

Emergency Department

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This project is funded by the National Institute for Health Research (NIHR) HS&DR programme (project reference 13/58/08). The work was also supported by a legacy provided by the family of Dr James Haigh. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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AH, JH and EG conceived of the research. AH was the programme lead. CCM, SS and EG conducted the interviews. DR and EG conducted the analysis. DR and EG wrote the first draft of the manuscript. All authors (DR, EG, SS, CCM, JH, AH) contributed to the manuscript. All authors have read and approved the final manuscript.

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Romeu, D., Guthrie, E., Saraiva, S. et al. Experiences of delivering and receiving mental healthcare in the acute hospital setting: a qualitative study. BMC Health Serv Res 24 , 191 (2024). https://doi.org/10.1186/s12913-024-10662-4

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What is qualitative research? If we look for a precise definition of qualitative research, and specifically for one that addresses its distinctive feature of being “qualitative,” the literature is meager. In this article we systematically search, identify and analyze a sample of 89 sources using or attempting to define the term “qualitative.” Then, drawing on ideas we find scattered across existing work, and based on Becker’s classic study of marijuana consumption, we formulate and illustrate a definition that tries to capture its core elements. We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. This formulation is developed as a tool to help improve research designs while stressing that a qualitative dimension is present in quantitative work as well. Additionally, it can facilitate teaching, communication between researchers, diminish the gap between qualitative and quantitative researchers, help to address critiques of qualitative methods, and be used as a standard of evaluation of qualitative research.

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If we assume that there is something called qualitative research, what exactly is this qualitative feature? And how could we evaluate qualitative research as good or not? Is it fundamentally different from quantitative research? In practice, most active qualitative researchers working with empirical material intuitively know what is involved in doing qualitative research, yet perhaps surprisingly, a clear definition addressing its key feature is still missing.

To address the question of what is qualitative we turn to the accounts of “qualitative research” in textbooks and also in empirical work. In his classic, explorative, interview study of deviance Howard Becker ( 1963 ) asks ‘How does one become a marijuana user?’ In contrast to pre-dispositional and psychological-individualistic theories of deviant behavior, Becker’s inherently social explanation contends that becoming a user of this substance is the result of a three-phase sequential learning process. First, potential users need to learn how to smoke it properly to produce the “correct” effects. If not, they are likely to stop experimenting with it. Second, they need to discover the effects associated with it; in other words, to get “high,” individuals not only have to experience what the drug does, but also to become aware that those sensations are related to using it. Third, they require learning to savor the feelings related to its consumption – to develop an acquired taste. Becker, who played music himself, gets close to the phenomenon by observing, taking part, and by talking to people consuming the drug: “half of the fifty interviews were conducted with musicians, the other half covered a wide range of people, including laborers, machinists, and people in the professions” (Becker 1963 :56).

Another central aspect derived through the common-to-all-research interplay between induction and deduction (Becker 2017 ), is that during the course of his research Becker adds scientifically meaningful new distinctions in the form of three phases—distinctions, or findings if you will, that strongly affect the course of his research: its focus, the material that he collects, and which eventually impact his findings. Each phase typically unfolds through social interaction, and often with input from experienced users in “a sequence of social experiences during which the person acquires a conception of the meaning of the behavior, and perceptions and judgments of objects and situations, all of which make the activity possible and desirable” (Becker 1963 :235). In this study the increased understanding of smoking dope is a result of a combination of the meaning of the actors, and the conceptual distinctions that Becker introduces based on the views expressed by his respondents. Understanding is the result of research and is due to an iterative process in which data, concepts and evidence are connected with one another (Becker 2017 ).

Indeed, there are many definitions of qualitative research, but if we look for a definition that addresses its distinctive feature of being “qualitative,” the literature across the broad field of social science is meager. The main reason behind this article lies in the paradox, which, to put it bluntly, is that researchers act as if they know what it is, but they cannot formulate a coherent definition. Sociologists and others will of course continue to conduct good studies that show the relevance and value of qualitative research addressing scientific and practical problems in society. However, our paper is grounded in the idea that providing a clear definition will help us improve the work that we do. Among researchers who practice qualitative research there is clearly much knowledge. We suggest that a definition makes this knowledge more explicit. If the first rationale for writing this paper refers to the “internal” aim of improving qualitative research, the second refers to the increased “external” pressure that especially many qualitative researchers feel; pressure that comes both from society as well as from other scientific approaches. There is a strong core in qualitative research, and leading researchers tend to agree on what it is and how it is done. Our critique is not directed at the practice of qualitative research, but we do claim that the type of systematic work we do has not yet been done, and that it is useful to improve the field and its status in relation to quantitative research.

The literature on the “internal” aim of improving, or at least clarifying qualitative research is large, and we do not claim to be the first to notice the vagueness of the term “qualitative” (Strauss and Corbin 1998 ). Also, others have noted that there is no single definition of it (Long and Godfrey 2004 :182), that there are many different views on qualitative research (Denzin and Lincoln 2003 :11; Jovanović 2011 :3), and that more generally, we need to define its meaning (Best 2004 :54). Strauss and Corbin ( 1998 ), for example, as well as Nelson et al. (1992:2 cited in Denzin and Lincoln 2003 :11), and Flick ( 2007 :ix–x), have recognized that the term is problematic: “Actually, the term ‘qualitative research’ is confusing because it can mean different things to different people” (Strauss and Corbin 1998 :10–11). Hammersley has discussed the possibility of addressing the problem, but states that “the task of providing an account of the distinctive features of qualitative research is far from straightforward” ( 2013 :2). This confusion, as he has recently further argued (Hammersley 2018 ), is also salient in relation to ethnography where different philosophical and methodological approaches lead to a lack of agreement about what it means.

Others (e.g. Hammersley 2018 ; Fine and Hancock 2017 ) have also identified the treat to qualitative research that comes from external forces, seen from the point of view of “qualitative research.” This threat can be further divided into that which comes from inside academia, such as the critique voiced by “quantitative research” and outside of academia, including, for example, New Public Management. Hammersley ( 2018 ), zooming in on one type of qualitative research, ethnography, has argued that it is under treat. Similarly to Fine ( 2003 ), and before him Gans ( 1999 ), he writes that ethnography’ has acquired a range of meanings, and comes in many different versions, these often reflecting sharply divergent epistemological orientations. And already more than twenty years ago while reviewing Denzin and Lincoln’ s Handbook of Qualitative Methods Fine argued:

While this increasing centrality [of qualitative research] might lead one to believe that consensual standards have developed, this belief would be misleading. As the methodology becomes more widely accepted, querulous challengers have raised fundamental questions that collectively have undercut the traditional models of how qualitative research is to be fashioned and presented (1995:417).

According to Hammersley, there are today “serious treats to the practice of ethnographic work, on almost any definition” ( 2018 :1). He lists five external treats: (1) that social research must be accountable and able to show its impact on society; (2) the current emphasis on “big data” and the emphasis on quantitative data and evidence; (3) the labor market pressure in academia that leaves less time for fieldwork (see also Fine and Hancock 2017 ); (4) problems of access to fields; and (5) the increased ethical scrutiny of projects, to which ethnography is particularly exposed. Hammersley discusses some more or less insufficient existing definitions of ethnography.

The current situation, as Hammersley and others note—and in relation not only to ethnography but also qualitative research in general, and as our empirical study shows—is not just unsatisfactory, it may even be harmful for the entire field of qualitative research, and does not help social science at large. We suggest that the lack of clarity of qualitative research is a real problem that must be addressed.

Towards a Definition of Qualitative Research

Seen in an historical light, what is today called qualitative, or sometimes ethnographic, interpretative research – or a number of other terms – has more or less always existed. At the time the founders of sociology – Simmel, Weber, Durkheim and, before them, Marx – were writing, and during the era of the Methodenstreit (“dispute about methods”) in which the German historical school emphasized scientific methods (cf. Swedberg 1990 ), we can at least speak of qualitative forerunners.

Perhaps the most extended discussion of what later became known as qualitative methods in a classic work is Bronisław Malinowski’s ( 1922 ) Argonauts in the Western Pacific , although even this study does not explicitly address the meaning of “qualitative.” In Weber’s ([1921–-22] 1978) work we find a tension between scientific explanations that are based on observation and quantification and interpretative research (see also Lazarsfeld and Barton 1982 ).

If we look through major sociology journals like the American Sociological Review , American Journal of Sociology , or Social Forces we will not find the term qualitative sociology before the 1970s. And certainly before then much of what we consider qualitative classics in sociology, like Becker’ study ( 1963 ), had already been produced. Indeed, the Chicago School often combined qualitative and quantitative data within the same study (Fine 1995 ). Our point being that before a disciplinary self-awareness the term quantitative preceded qualitative, and the articulation of the former was a political move to claim scientific status (Denzin and Lincoln 2005 ). In the US the World War II seem to have sparked a critique of sociological work, including “qualitative work,” that did not follow the scientific canon (Rawls 2018 ), which was underpinned by a scientifically oriented and value free philosophy of science. As a result the attempts and practice of integrating qualitative and quantitative sociology at Chicago lost ground to sociology that was more oriented to surveys and quantitative work at Columbia under Merton-Lazarsfeld. The quantitative tradition was also able to present textbooks (Lundberg 1951 ) that facilitated the use this approach and its “methods.” The practices of the qualitative tradition, by and large, remained tacit or was part of the mentoring transferred from the renowned masters to their students.

This glimpse into history leads us back to the lack of a coherent account condensed in a definition of qualitative research. Many of the attempts to define the term do not meet the requirements of a proper definition: A definition should be clear, avoid tautology, demarcate its domain in relation to the environment, and ideally only use words in its definiens that themselves are not in need of definition (Hempel 1966 ). A definition can enhance precision and thus clarity by identifying the core of the phenomenon. Preferably, a definition should be short. The typical definition we have found, however, is an ostensive definition, which indicates what qualitative research is about without informing us about what it actually is :

Qualitative research is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret, phenomena in terms of the meanings people bring to them. Qualitative research involves the studied use and collection of a variety of empirical materials – case study, personal experience, introspective, life story, interview, observational, historical, interactional, and visual texts – that describe routine and problematic moments and meanings in individuals’ lives. (Denzin and Lincoln 2005 :2)

Flick claims that the label “qualitative research” is indeed used as an umbrella for a number of approaches ( 2007 :2–4; 2002 :6), and it is not difficult to identify research fitting this designation. Moreover, whatever it is, it has grown dramatically over the past five decades. In addition, courses have been developed, methods have flourished, arguments about its future have been advanced (for example, Denzin and Lincoln 1994) and criticized (for example, Snow and Morrill 1995 ), and dedicated journals and books have mushroomed. Most social scientists have a clear idea of research and how it differs from journalism, politics and other activities. But the question of what is qualitative in qualitative research is either eluded or eschewed.

We maintain that this lacuna hinders systematic knowledge production based on qualitative research. Paul Lazarsfeld noted the lack of “codification” as early as 1955 when he reviewed 100 qualitative studies in order to offer a codification of the practices (Lazarsfeld and Barton 1982 :239). Since then many texts on “qualitative research” and its methods have been published, including recent attempts (Goertz and Mahoney 2012 ) similar to Lazarsfeld’s. These studies have tried to extract what is qualitative by looking at the large number of empirical “qualitative” studies. Our novel strategy complements these endeavors by taking another approach and looking at the attempts to codify these practices in the form of a definition, as well as to a minor extent take Becker’s study as an exemplar of what qualitative researchers actually do, and what the characteristic of being ‘qualitative’ denotes and implies. We claim that qualitative researchers, if there is such a thing as “qualitative research,” should be able to codify their practices in a condensed, yet general way expressed in language.

Lingering problems of “generalizability” and “how many cases do I need” (Small 2009 ) are blocking advancement – in this line of work qualitative approaches are said to differ considerably from quantitative ones, while some of the former unsuccessfully mimic principles related to the latter (Small 2009 ). Additionally, quantitative researchers sometimes unfairly criticize the first based on their own quality criteria. Scholars like Goertz and Mahoney ( 2012 ) have successfully focused on the different norms and practices beyond what they argue are essentially two different cultures: those working with either qualitative or quantitative methods. Instead, similarly to Becker ( 2017 ) who has recently questioned the usefulness of the distinction between qualitative and quantitative research, we focus on similarities.

The current situation also impedes both students and researchers in focusing their studies and understanding each other’s work (Lazarsfeld and Barton 1982 :239). A third consequence is providing an opening for critiques by scholars operating within different traditions (Valsiner 2000 :101). A fourth issue is that the “implicit use of methods in qualitative research makes the field far less standardized than the quantitative paradigm” (Goertz and Mahoney 2012 :9). Relatedly, the National Science Foundation in the US organized two workshops in 2004 and 2005 to address the scientific foundations of qualitative research involving strategies to improve it and to develop standards of evaluation in qualitative research. However, a specific focus on its distinguishing feature of being “qualitative” while being implicitly acknowledged, was discussed only briefly (for example, Best 2004 ).

In 2014 a theme issue was published in this journal on “Methods, Materials, and Meanings: Designing Cultural Analysis,” discussing central issues in (cultural) qualitative research (Berezin 2014 ; Biernacki 2014 ; Glaeser 2014 ; Lamont and Swidler 2014 ; Spillman 2014). We agree with many of the arguments put forward, such as the risk of methodological tribalism, and that we should not waste energy on debating methods separated from research questions. Nonetheless, a clarification of the relation to what is called “quantitative research” is of outmost importance to avoid misunderstandings and misguided debates between “qualitative” and “quantitative” researchers. Our strategy means that researchers, “qualitative” or “quantitative” they may be, in their actual practice may combine qualitative work and quantitative work.

In this article we accomplish three tasks. First, we systematically survey the literature for meanings of qualitative research by looking at how researchers have defined it. Drawing upon existing knowledge we find that the different meanings and ideas of qualitative research are not yet coherently integrated into one satisfactory definition. Next, we advance our contribution by offering a definition of qualitative research and illustrate its meaning and use partially by expanding on the brief example introduced earlier related to Becker’s work ( 1963 ). We offer a systematic analysis of central themes of what researchers consider to be the core of “qualitative,” regardless of style of work. These themes – which we summarize in terms of four keywords: distinction, process, closeness, improved understanding – constitute part of our literature review, in which each one appears, sometimes with others, but never all in the same definition. They serve as the foundation of our contribution. Our categories are overlapping. Their use is primarily to organize the large amount of definitions we have identified and analyzed, and not necessarily to draw a clear distinction between them. Finally, we continue the elaboration discussed above on the advantages of a clear definition of qualitative research.

In a hermeneutic fashion we propose that there is something meaningful that deserves to be labelled “qualitative research” (Gadamer 1990 ). To approach the question “What is qualitative in qualitative research?” we have surveyed the literature. In conducting our survey we first traced the word’s etymology in dictionaries, encyclopedias, handbooks of the social sciences and of methods and textbooks, mainly in English, which is common to methodology courses. It should be noted that we have zoomed in on sociology and its literature. This discipline has been the site of the largest debate and development of methods that can be called “qualitative,” which suggests that this field should be examined in great detail.

In an ideal situation we should expect that one good definition, or at least some common ideas, would have emerged over the years. This common core of qualitative research should be so accepted that it would appear in at least some textbooks. Since this is not what we found, we decided to pursue an inductive approach to capture maximal variation in the field of qualitative research; we searched in a selection of handbooks, textbooks, book chapters, and books, to which we added the analysis of journal articles. Our sample comprises a total of 89 references.

In practice we focused on the discipline that has had a clear discussion of methods, namely sociology. We also conducted a broad search in the JSTOR database to identify scholarly sociology articles published between 1998 and 2017 in English with a focus on defining or explaining qualitative research. We specifically zoom in on this time frame because we would have expect that this more mature period would have produced clear discussions on the meaning of qualitative research. To find these articles we combined a number of keywords to search the content and/or the title: qualitative (which was always included), definition, empirical, research, methodology, studies, fieldwork, interview and observation .

As a second phase of our research we searched within nine major sociological journals ( American Journal of Sociology , Sociological Theory , American Sociological Review , Contemporary Sociology , Sociological Forum , Sociological Theory , Qualitative Research , Qualitative Sociology and Qualitative Sociology Review ) for articles also published during the past 19 years (1998–2017) that had the term “qualitative” in the title and attempted to define qualitative research.

Lastly we picked two additional journals, Qualitative Research and Qualitative Sociology , in which we could expect to find texts addressing the notion of “qualitative.” From Qualitative Research we chose Volume 14, Issue 6, December 2014, and from Qualitative Sociology we chose Volume 36, Issue 2, June 2017. Within each of these we selected the first article; then we picked the second article of three prior issues. Again we went back another three issues and investigated article number three. Finally we went back another three issues and perused article number four. This selection criteria was used to get a manageable sample for the analysis.

The coding process of the 89 references we gathered in our selected review began soon after the first round of material was gathered, and we reduced the complexity created by our maximum variation sampling (Snow and Anderson 1993 :22) to four different categories within which questions on the nature and properties of qualitative research were discussed. We call them: Qualitative and Quantitative Research, Qualitative Research, Fieldwork, and Grounded Theory. This – which may appear as an illogical grouping – merely reflects the “context” in which the matter of “qualitative” is discussed. If the selection process of the material – books and articles – was informed by pre-knowledge, we used an inductive strategy to code the material. When studying our material, we identified four central notions related to “qualitative” that appear in various combinations in the literature which indicate what is the core of qualitative research. We have labeled them: “distinctions”, “process,” “closeness,” and “improved understanding.” During the research process the categories and notions were improved, refined, changed, and reordered. The coding ended when a sense of saturation in the material arose. In the presentation below all quotations and references come from our empirical material of texts on qualitative research.

Analysis – What is Qualitative Research?

In this section we describe the four categories we identified in the coding, how they differently discuss qualitative research, as well as their overall content. Some salient quotations are selected to represent the type of text sorted under each of the four categories. What we present are examples from the literature.

Qualitative and Quantitative

This analytic category comprises quotations comparing qualitative and quantitative research, a distinction that is frequently used (Brown 2010 :231); in effect this is a conceptual pair that structures the discussion and that may be associated with opposing interests. While the general goal of quantitative and qualitative research is the same – to understand the world better – their methodologies and focus in certain respects differ substantially (Becker 1966 :55). Quantity refers to that property of something that can be determined by measurement. In a dictionary of Statistics and Methodology we find that “(a) When referring to *variables, ‘qualitative’ is another term for *categorical or *nominal. (b) When speaking of kinds of research, ‘qualitative’ refers to studies of subjects that are hard to quantify, such as art history. Qualitative research tends to be a residual category for almost any kind of non-quantitative research” (Stiles 1998:183). But it should be obvious that one could employ a quantitative approach when studying, for example, art history.

The same dictionary states that quantitative is “said of variables or research that can be handled numerically, usually (too sharply) contrasted with *qualitative variables and research” (Stiles 1998:184). From a qualitative perspective “quantitative research” is about numbers and counting, and from a quantitative perspective qualitative research is everything that is not about numbers. But this does not say much about what is “qualitative.” If we turn to encyclopedias we find that in the 1932 edition of the Encyclopedia of the Social Sciences there is no mention of “qualitative.” In the Encyclopedia from 1968 we can read:

Qualitative Analysis. For methods of obtaining, analyzing, and describing data, see [the various entries:] CONTENT ANALYSIS; COUNTED DATA; EVALUATION RESEARCH, FIELD WORK; GRAPHIC PRESENTATION; HISTORIOGRAPHY, especially the article on THE RHETORIC OF HISTORY; INTERVIEWING; OBSERVATION; PERSONALITY MEASUREMENT; PROJECTIVE METHODS; PSYCHOANALYSIS, article on EXPERIMENTAL METHODS; SURVEY ANALYSIS, TABULAR PRESENTATION; TYPOLOGIES. (Vol. 13:225)

Some, like Alford, divide researchers into methodologists or, in his words, “quantitative and qualitative specialists” (Alford 1998 :12). Qualitative research uses a variety of methods, such as intensive interviews or in-depth analysis of historical materials, and it is concerned with a comprehensive account of some event or unit (King et al. 1994 :4). Like quantitative research it can be utilized to study a variety of issues, but it tends to focus on meanings and motivations that underlie cultural symbols, personal experiences, phenomena and detailed understanding of processes in the social world. In short, qualitative research centers on understanding processes, experiences, and the meanings people assign to things (Kalof et al. 2008 :79).

Others simply say that qualitative methods are inherently unscientific (Jovanović 2011 :19). Hood, for instance, argues that words are intrinsically less precise than numbers, and that they are therefore more prone to subjective analysis, leading to biased results (Hood 2006 :219). Qualitative methodologies have raised concerns over the limitations of quantitative templates (Brady et al. 2004 :4). Scholars such as King et al. ( 1994 ), for instance, argue that non-statistical research can produce more reliable results if researchers pay attention to the rules of scientific inference commonly stated in quantitative research. Also, researchers such as Becker ( 1966 :59; 1970 :42–43) have asserted that, if conducted properly, qualitative research and in particular ethnographic field methods, can lead to more accurate results than quantitative studies, in particular, survey research and laboratory experiments.

Some researchers, such as Kalof, Dan, and Dietz ( 2008 :79) claim that the boundaries between the two approaches are becoming blurred, and Small ( 2009 ) argues that currently much qualitative research (especially in North America) tries unsuccessfully and unnecessarily to emulate quantitative standards. For others, qualitative research tends to be more humanistic and discursive (King et al. 1994 :4). Ragin ( 1994 ), and similarly also Becker, ( 1996 :53), Marchel and Owens ( 2007 :303) think that the main distinction between the two styles is overstated and does not rest on the simple dichotomy of “numbers versus words” (Ragin 1994 :xii). Some claim that quantitative data can be utilized to discover associations, but in order to unveil cause and effect a complex research design involving the use of qualitative approaches needs to be devised (Gilbert 2009 :35). Consequently, qualitative data are useful for understanding the nuances lying beyond those processes as they unfold (Gilbert 2009 :35). Others contend that qualitative research is particularly well suited both to identify causality and to uncover fine descriptive distinctions (Fine and Hallett 2014 ; Lichterman and Isaac Reed 2014 ; Katz 2015 ).

There are other ways to separate these two traditions, including normative statements about what qualitative research should be (that is, better or worse than quantitative approaches, concerned with scientific approaches to societal change or vice versa; Snow and Morrill 1995 ; Denzin and Lincoln 2005 ), or whether it should develop falsifiable statements; Best 2004 ).

We propose that quantitative research is largely concerned with pre-determined variables (Small 2008 ); the analysis concerns the relations between variables. These categories are primarily not questioned in the study, only their frequency or degree, or the correlations between them (cf. Franzosi 2016 ). If a researcher studies wage differences between women and men, he or she works with given categories: x number of men are compared with y number of women, with a certain wage attributed to each person. The idea is not to move beyond the given categories of wage, men and women; they are the starting point as well as the end point, and undergo no “qualitative change.” Qualitative research, in contrast, investigates relations between categories that are themselves subject to change in the research process. Returning to Becker’s study ( 1963 ), we see that he questioned pre-dispositional theories of deviant behavior working with pre-determined variables such as an individual’s combination of personal qualities or emotional problems. His take, in contrast, was to understand marijuana consumption by developing “variables” as part of the investigation. Thereby he presented new variables, or as we would say today, theoretical concepts, but which are grounded in the empirical material.

Qualitative Research

This category contains quotations that refer to descriptions of qualitative research without making comparisons with quantitative research. Researchers such as Denzin and Lincoln, who have written a series of influential handbooks on qualitative methods (1994; Denzin and Lincoln 2003 ; 2005 ), citing Nelson et al. (1992:4), argue that because qualitative research is “interdisciplinary, transdisciplinary, and sometimes counterdisciplinary” it is difficult to derive one single definition of it (Jovanović 2011 :3). According to them, in fact, “the field” is “many things at the same time,” involving contradictions, tensions over its focus, methods, and how to derive interpretations and findings ( 2003 : 11). Similarly, others, such as Flick ( 2007 :ix–x) contend that agreeing on an accepted definition has increasingly become problematic, and that qualitative research has possibly matured different identities. However, Best holds that “the proliferation of many sorts of activities under the label of qualitative sociology threatens to confuse our discussions” ( 2004 :54). Atkinson’s position is more definite: “the current state of qualitative research and research methods is confused” ( 2005 :3–4).

Qualitative research is about interpretation (Blumer 1969 ; Strauss and Corbin 1998 ; Denzin and Lincoln 2003 ), or Verstehen [understanding] (Frankfort-Nachmias and Nachmias 1996 ). It is “multi-method,” involving the collection and use of a variety of empirical materials (Denzin and Lincoln 1998; Silverman 2013 ) and approaches (Silverman 2005 ; Flick 2007 ). It focuses not only on the objective nature of behavior but also on its subjective meanings: individuals’ own accounts of their attitudes, motivations, behavior (McIntyre 2005 :127; Creswell 2009 ), events and situations (Bryman 1989) – what people say and do in specific places and institutions (Goodwin and Horowitz 2002 :35–36) in social and temporal contexts (Morrill and Fine 1997). For this reason, following Weber ([1921-22] 1978), it can be described as an interpretative science (McIntyre 2005 :127). But could quantitative research also be concerned with these questions? Also, as pointed out below, does all qualitative research focus on subjective meaning, as some scholars suggest?

Others also distinguish qualitative research by claiming that it collects data using a naturalistic approach (Denzin and Lincoln 2005 :2; Creswell 2009 ), focusing on the meaning actors ascribe to their actions. But again, does all qualitative research need to be collected in situ? And does qualitative research have to be inherently concerned with meaning? Flick ( 2007 ), referring to Denzin and Lincoln ( 2005 ), mentions conversation analysis as an example of qualitative research that is not concerned with the meanings people bring to a situation, but rather with the formal organization of talk. Still others, such as Ragin ( 1994 :85), note that qualitative research is often (especially early on in the project, we would add) less structured than other kinds of social research – a characteristic connected to its flexibility and that can lead both to potentially better, but also worse results. But is this not a feature of this type of research, rather than a defining description of its essence? Wouldn’t this comment also apply, albeit to varying degrees, to quantitative research?

In addition, Strauss ( 2003 ), along with others, such as Alvesson and Kärreman ( 2011 :10–76), argue that qualitative researchers struggle to capture and represent complex phenomena partially because they tend to collect a large amount of data. While his analysis is correct at some points – “It is necessary to do detailed, intensive, microscopic examination of the data in order to bring out the amazing complexity of what lies in, behind, and beyond those data” (Strauss 2003 :10) – much of his analysis concerns the supposed focus of qualitative research and its challenges, rather than exactly what it is about. But even in this instance we would make a weak case arguing that these are strictly the defining features of qualitative research. Some researchers seem to focus on the approach or the methods used, or even on the way material is analyzed. Several researchers stress the naturalistic assumption of investigating the world, suggesting that meaning and interpretation appear to be a core matter of qualitative research.

We can also see that in this category there is no consensus about specific qualitative methods nor about qualitative data. Many emphasize interpretation, but quantitative research, too, involves interpretation; the results of a regression analysis, for example, certainly have to be interpreted, and the form of meta-analysis that factor analysis provides indeed requires interpretation However, there is no interpretation of quantitative raw data, i.e., numbers in tables. One common thread is that qualitative researchers have to get to grips with their data in order to understand what is being studied in great detail, irrespective of the type of empirical material that is being analyzed. This observation is connected to the fact that qualitative researchers routinely make several adjustments of focus and research design as their studies progress, in many cases until the very end of the project (Kalof et al. 2008 ). If you, like Becker, do not start out with a detailed theory, adjustments such as the emergence and refinement of research questions will occur during the research process. We have thus found a number of useful reflections about qualitative research scattered across different sources, but none of them effectively describe the defining characteristics of this approach.

Although qualitative research does not appear to be defined in terms of a specific method, it is certainly common that fieldwork, i.e., research that entails that the researcher spends considerable time in the field that is studied and use the knowledge gained as data, is seen as emblematic of or even identical to qualitative research. But because we understand that fieldwork tends to focus primarily on the collection and analysis of qualitative data, we expected to find within it discussions on the meaning of “qualitative.” But, again, this was not the case.

Instead, we found material on the history of this approach (for example, Frankfort-Nachmias and Nachmias 1996 ; Atkinson et al. 2001), including how it has changed; for example, by adopting a more self-reflexive practice (Heyl 2001), as well as the different nomenclature that has been adopted, such as fieldwork, ethnography, qualitative research, naturalistic research, participant observation and so on (for example, Lofland et al. 2006 ; Gans 1999 ).

We retrieved definitions of ethnography, such as “the study of people acting in the natural courses of their daily lives,” involving a “resocialization of the researcher” (Emerson 1988 :1) through intense immersion in others’ social worlds (see also examples in Hammersley 2018 ). This may be accomplished by direct observation and also participation (Neuman 2007 :276), although others, such as Denzin ( 1970 :185), have long recognized other types of observation, including non-participant (“fly on the wall”). In this category we have also isolated claims and opposing views, arguing that this type of research is distinguished primarily by where it is conducted (natural settings) (Hughes 1971:496), and how it is carried out (a variety of methods are applied) or, for some most importantly, by involving an active, empathetic immersion in those being studied (Emerson 1988 :2). We also retrieved descriptions of the goals it attends in relation to how it is taught (understanding subjective meanings of the people studied, primarily develop theory, or contribute to social change) (see for example, Corte and Irwin 2017 ; Frankfort-Nachmias and Nachmias 1996 :281; Trier-Bieniek 2012 :639) by collecting the richest possible data (Lofland et al. 2006 ) to derive “thick descriptions” (Geertz 1973 ), and/or to aim at theoretical statements of general scope and applicability (for example, Emerson 1988 ; Fine 2003 ). We have identified guidelines on how to evaluate it (for example Becker 1996 ; Lamont 2004 ) and have retrieved instructions on how it should be conducted (for example, Lofland et al. 2006 ). For instance, analysis should take place while the data gathering unfolds (Emerson 1988 ; Hammersley and Atkinson 2007 ; Lofland et al. 2006 ), observations should be of long duration (Becker 1970 :54; Goffman 1989 ), and data should be of high quantity (Becker 1970 :52–53), as well as other questionable distinctions between fieldwork and other methods:

Field studies differ from other methods of research in that the researcher performs the task of selecting topics, decides what questions to ask, and forges interest in the course of the research itself . This is in sharp contrast to many ‘theory-driven’ and ‘hypothesis-testing’ methods. (Lofland and Lofland 1995 :5)

But could not, for example, a strictly interview-based study be carried out with the same amount of flexibility, such as sequential interviewing (for example, Small 2009 )? Once again, are quantitative approaches really as inflexible as some qualitative researchers think? Moreover, this category stresses the role of the actors’ meaning, which requires knowledge and close interaction with people, their practices and their lifeworld.

It is clear that field studies – which are seen by some as the “gold standard” of qualitative research – are nonetheless only one way of doing qualitative research. There are other methods, but it is not clear why some are more qualitative than others, or why they are better or worse. Fieldwork is characterized by interaction with the field (the material) and understanding of the phenomenon that is being studied. In Becker’s case, he had general experience from fields in which marihuana was used, based on which he did interviews with actual users in several fields.

Grounded Theory

Another major category we identified in our sample is Grounded Theory. We found descriptions of it most clearly in Glaser and Strauss’ ([1967] 2010 ) original articulation, Strauss and Corbin ( 1998 ) and Charmaz ( 2006 ), as well as many other accounts of what it is for: generating and testing theory (Strauss 2003 :xi). We identified explanations of how this task can be accomplished – such as through two main procedures: constant comparison and theoretical sampling (Emerson 1998:96), and how using it has helped researchers to “think differently” (for example, Strauss and Corbin 1998 :1). We also read descriptions of its main traits, what it entails and fosters – for instance, an exceptional flexibility, an inductive approach (Strauss and Corbin 1998 :31–33; 1990; Esterberg 2002 :7), an ability to step back and critically analyze situations, recognize tendencies towards bias, think abstractly and be open to criticism, enhance sensitivity towards the words and actions of respondents, and develop a sense of absorption and devotion to the research process (Strauss and Corbin 1998 :5–6). Accordingly, we identified discussions of the value of triangulating different methods (both using and not using grounded theory), including quantitative ones, and theories to achieve theoretical development (most comprehensively in Denzin 1970 ; Strauss and Corbin 1998 ; Timmermans and Tavory 2012 ). We have also located arguments about how its practice helps to systematize data collection, analysis and presentation of results (Glaser and Strauss [1967] 2010 :16).

Grounded theory offers a systematic approach which requires researchers to get close to the field; closeness is a requirement of identifying questions and developing new concepts or making further distinctions with regard to old concepts. In contrast to other qualitative approaches, grounded theory emphasizes the detailed coding process, and the numerous fine-tuned distinctions that the researcher makes during the process. Within this category, too, we could not find a satisfying discussion of the meaning of qualitative research.

Defining Qualitative Research

In sum, our analysis shows that some notions reappear in the discussion of qualitative research, such as understanding, interpretation, “getting close” and making distinctions. These notions capture aspects of what we think is “qualitative.” However, a comprehensive definition that is useful and that can further develop the field is lacking, and not even a clear picture of its essential elements appears. In other words no definition emerges from our data, and in our research process we have moved back and forth between our empirical data and the attempt to present a definition. Our concrete strategy, as stated above, is to relate qualitative and quantitative research, or more specifically, qualitative and quantitative work. We use an ideal-typical notion of quantitative research which relies on taken for granted and numbered variables. This means that the data consists of variables on different scales, such as ordinal, but frequently ratio and absolute scales, and the representation of the numbers to the variables, i.e. the justification of the assignment of numbers to object or phenomenon, are not questioned, though the validity may be questioned. In this section we return to the notion of quality and try to clarify it while presenting our contribution.

Broadly, research refers to the activity performed by people trained to obtain knowledge through systematic procedures. Notions such as “objectivity” and “reflexivity,” “systematic,” “theory,” “evidence” and “openness” are here taken for granted in any type of research. Next, building on our empirical analysis we explain the four notions that we have identified as central to qualitative work: distinctions, process, closeness, and improved understanding. In discussing them, ultimately in relation to one another, we make their meaning even more precise. Our idea, in short, is that only when these ideas that we present separately for analytic purposes are brought together can we speak of qualitative research.

Distinctions

We believe that the possibility of making new distinctions is one the defining characteristics of qualitative research. It clearly sets it apart from quantitative analysis which works with taken-for-granted variables, albeit as mentioned, meta-analyses, for example, factor analysis may result in new variables. “Quality” refers essentially to distinctions, as already pointed out by Aristotle. He discusses the term “qualitative” commenting: “By a quality I mean that in virtue of which things are said to be qualified somehow” (Aristotle 1984:14). Quality is about what something is or has, which means that the distinction from its environment is crucial. We see qualitative research as a process in which significant new distinctions are made to the scholarly community; to make distinctions is a key aspect of obtaining new knowledge; a point, as we will see, that also has implications for “quantitative research.” The notion of being “significant” is paramount. New distinctions by themselves are not enough; just adding concepts only increases complexity without furthering our knowledge. The significance of new distinctions is judged against the communal knowledge of the research community. To enable this discussion and judgements central elements of rational discussion are required (cf. Habermas [1981] 1987 ; Davidsson [ 1988 ] 2001) to identify what is new and relevant scientific knowledge. Relatedly, Ragin alludes to the idea of new and useful knowledge at a more concrete level: “Qualitative methods are appropriate for in-depth examination of cases because they aid the identification of key features of cases. Most qualitative methods enhance data” (1994:79). When Becker ( 1963 ) studied deviant behavior and investigated how people became marihuana smokers, he made distinctions between the ways in which people learned how to smoke. This is a classic example of how the strategy of “getting close” to the material, for example the text, people or pictures that are subject to analysis, may enable researchers to obtain deeper insight and new knowledge by making distinctions – in this instance on the initial notion of learning how to smoke. Others have stressed the making of distinctions in relation to coding or theorizing. Emerson et al. ( 1995 ), for example, hold that “qualitative coding is a way of opening up avenues of inquiry,” meaning that the researcher identifies and develops concepts and analytic insights through close examination of and reflection on data (Emerson et al. 1995 :151). Goodwin and Horowitz highlight making distinctions in relation to theory-building writing: “Close engagement with their cases typically requires qualitative researchers to adapt existing theories or to make new conceptual distinctions or theoretical arguments to accommodate new data” ( 2002 : 37). In the ideal-typical quantitative research only existing and so to speak, given, variables would be used. If this is the case no new distinction are made. But, would not also many “quantitative” researchers make new distinctions?

Process does not merely suggest that research takes time. It mainly implies that qualitative new knowledge results from a process that involves several phases, and above all iteration. Qualitative research is about oscillation between theory and evidence, analysis and generating material, between first- and second -order constructs (Schütz 1962 :59), between getting in contact with something, finding sources, becoming deeply familiar with a topic, and then distilling and communicating some of its essential features. The main point is that the categories that the researcher uses, and perhaps takes for granted at the beginning of the research process, usually undergo qualitative changes resulting from what is found. Becker describes how he tested hypotheses and let the jargon of the users develop into theoretical concepts. This happens over time while the study is being conducted, exemplifying what we mean by process.

In the research process, a pilot-study may be used to get a first glance of, for example, the field, how to approach it, and what methods can be used, after which the method and theory are chosen or refined before the main study begins. Thus, the empirical material is often central from the start of the project and frequently leads to adjustments by the researcher. Likewise, during the main study categories are not fixed; the empirical material is seen in light of the theory used, but it is also given the opportunity to kick back, thereby resisting attempts to apply theoretical straightjackets (Becker 1970 :43). In this process, coding and analysis are interwoven, and thus are often important steps for getting closer to the phenomenon and deciding what to focus on next. Becker began his research by interviewing musicians close to him, then asking them to refer him to other musicians, and later on doubling his original sample of about 25 to include individuals in other professions (Becker 1973:46). Additionally, he made use of some participant observation, documents, and interviews with opiate users made available to him by colleagues. As his inductive theory of deviance evolved, Becker expanded his sample in order to fine tune it, and test the accuracy and generality of his hypotheses. In addition, he introduced a negative case and discussed the null hypothesis ( 1963 :44). His phasic career model is thus based on a research design that embraces processual work. Typically, process means to move between “theory” and “material” but also to deal with negative cases, and Becker ( 1998 ) describes how discovering these negative cases impacted his research design and ultimately its findings.

Obviously, all research is process-oriented to some degree. The point is that the ideal-typical quantitative process does not imply change of the data, and iteration between data, evidence, hypotheses, empirical work, and theory. The data, quantified variables, are, in most cases fixed. Merging of data, which of course can be done in a quantitative research process, does not mean new data. New hypotheses are frequently tested, but the “raw data is often the “the same.” Obviously, over time new datasets are made available and put into use.

Another characteristic that is emphasized in our sample is that qualitative researchers – and in particular ethnographers – can, or as Goffman put it, ought to ( 1989 ), get closer to the phenomenon being studied and their data than quantitative researchers (for example, Silverman 2009 :85). Put differently, essentially because of their methods qualitative researchers get into direct close contact with those being investigated and/or the material, such as texts, being analyzed. Becker started out his interview study, as we noted, by talking to those he knew in the field of music to get closer to the phenomenon he was studying. By conducting interviews he got even closer. Had he done more observations, he would undoubtedly have got even closer to the field.

Additionally, ethnographers’ design enables researchers to follow the field over time, and the research they do is almost by definition longitudinal, though the time in the field is studied obviously differs between studies. The general characteristic of closeness over time maximizes the chances of unexpected events, new data (related, for example, to archival research as additional sources, and for ethnography for situations not necessarily previously thought of as instrumental – what Mannay and Morgan ( 2015 ) term the “waiting field”), serendipity (Merton and Barber 2004 ; Åkerström 2013 ), and possibly reactivity, as well as the opportunity to observe disrupted patterns that translate into exemplars of negative cases. Two classic examples of this are Becker’s finding of what medical students call “crocks” (Becker et al. 1961 :317), and Geertz’s ( 1973 ) study of “deep play” in Balinese society.

By getting and staying so close to their data – be it pictures, text or humans interacting (Becker was himself a musician) – for a long time, as the research progressively focuses, qualitative researchers are prompted to continually test their hunches, presuppositions and hypotheses. They test them against a reality that often (but certainly not always), and practically, as well as metaphorically, talks back, whether by validating them, or disqualifying their premises – correctly, as well as incorrectly (Fine 2003 ; Becker 1970 ). This testing nonetheless often leads to new directions for the research. Becker, for example, says that he was initially reading psychological theories, but when facing the data he develops a theory that looks at, you may say, everything but psychological dispositions to explain the use of marihuana. Especially researchers involved with ethnographic methods have a fairly unique opportunity to dig up and then test (in a circular, continuous and temporal way) new research questions and findings as the research progresses, and thereby to derive previously unimagined and uncharted distinctions by getting closer to the phenomenon under study.

Let us stress that getting close is by no means restricted to ethnography. The notion of hermeneutic circle and hermeneutics as a general way of understanding implies that we must get close to the details in order to get the big picture. This also means that qualitative researchers can literally also make use of details of pictures as evidence (cf. Harper 2002). Thus, researchers may get closer both when generating the material or when analyzing it.

Quantitative research, we maintain, in the ideal-typical representation cannot get closer to the data. The data is essentially numbers in tables making up the variables (Franzosi 2016 :138). The data may originally have been “qualitative,” but once reduced to numbers there can only be a type of “hermeneutics” about what the number may stand for. The numbers themselves, however, are non-ambiguous. Thus, in quantitative research, interpretation, if done, is not about the data itself—the numbers—but what the numbers stand for. It follows that the interpretation is essentially done in a more “speculative” mode without direct empirical evidence (cf. Becker 2017 ).

Improved Understanding

While distinction, process and getting closer refer to the qualitative work of the researcher, improved understanding refers to its conditions and outcome of this work. Understanding cuts deeper than explanation, which to some may mean a causally verified correlation between variables. The notion of explanation presupposes the notion of understanding since explanation does not include an idea of how knowledge is gained (Manicas 2006 : 15). Understanding, we argue, is the core concept of what we call the outcome of the process when research has made use of all the other elements that were integrated in the research. Understanding, then, has a special status in qualitative research since it refers both to the conditions of knowledge and the outcome of the process. Understanding can to some extent be seen as the condition of explanation and occurs in a process of interpretation, which naturally refers to meaning (Gadamer 1990 ). It is fundamentally connected to knowing, and to the knowing of how to do things (Heidegger [1927] 2001 ). Conceptually the term hermeneutics is used to account for this process. Heidegger ties hermeneutics to human being and not possible to separate from the understanding of being ( 1988 ). Here we use it in a broader sense, and more connected to method in general (cf. Seiffert 1992 ). The abovementioned aspects – for example, “objectivity” and “reflexivity” – of the approach are conditions of scientific understanding. Understanding is the result of a circular process and means that the parts are understood in light of the whole, and vice versa. Understanding presupposes pre-understanding, or in other words, some knowledge of the phenomenon studied. The pre-understanding, even in the form of prejudices, are in qualitative research process, which we see as iterative, questioned, which gradually or suddenly change due to the iteration of data, evidence and concepts. However, qualitative research generates understanding in the iterative process when the researcher gets closer to the data, e.g., by going back and forth between field and analysis in a process that generates new data that changes the evidence, and, ultimately, the findings. Questioning, to ask questions, and put what one assumes—prejudices and presumption—in question, is central to understand something (Heidegger [1927] 2001 ; Gadamer 1990 :368–384). We propose that this iterative process in which the process of understanding occurs is characteristic of qualitative research.

Improved understanding means that we obtain scientific knowledge of something that we as a scholarly community did not know before, or that we get to know something better. It means that we understand more about how parts are related to one another, and to other things we already understand (see also Fine and Hallett 2014 ). Understanding is an important condition for qualitative research. It is not enough to identify correlations, make distinctions, and work in a process in which one gets close to the field or phenomena. Understanding is accomplished when the elements are integrated in an iterative process.

It is, moreover, possible to understand many things, and researchers, just like children, may come to understand new things every day as they engage with the world. This subjective condition of understanding – namely, that a person gains a better understanding of something –is easily met. To be qualified as “scientific,” the understanding must be general and useful to many; it must be public. But even this generally accessible understanding is not enough in order to speak of “scientific understanding.” Though we as a collective can increase understanding of everything in virtually all potential directions as a result also of qualitative work, we refrain from this “objective” way of understanding, which has no means of discriminating between what we gain in understanding. Scientific understanding means that it is deemed relevant from the scientific horizon (compare Schütz 1962 : 35–38, 46, 63), and that it rests on the pre-understanding that the scientists have and must have in order to understand. In other words, the understanding gained must be deemed useful by other researchers, so that they can build on it. We thus see understanding from a pragmatic, rather than a subjective or objective perspective. Improved understanding is related to the question(s) at hand. Understanding, in order to represent an improvement, must be an improvement in relation to the existing body of knowledge of the scientific community (James [ 1907 ] 1955). Scientific understanding is, by definition, collective, as expressed in Weber’s famous note on objectivity, namely that scientific work aims at truths “which … can claim, even for a Chinese, the validity appropriate to an empirical analysis” ([1904] 1949 :59). By qualifying “improved understanding” we argue that it is a general defining characteristic of qualitative research. Becker‘s ( 1966 ) study and other research of deviant behavior increased our understanding of the social learning processes of how individuals start a behavior. And it also added new knowledge about the labeling of deviant behavior as a social process. Few studies, of course, make the same large contribution as Becker’s, but are nonetheless qualitative research.

Understanding in the phenomenological sense, which is a hallmark of qualitative research, we argue, requires meaning and this meaning is derived from the context, and above all the data being analyzed. The ideal-typical quantitative research operates with given variables with different numbers. This type of material is not enough to establish meaning at the level that truly justifies understanding. In other words, many social science explanations offer ideas about correlations or even causal relations, but this does not mean that the meaning at the level of the data analyzed, is understood. This leads us to say that there are indeed many explanations that meet the criteria of understanding, for example the explanation of how one becomes a marihuana smoker presented by Becker. However, we may also understand a phenomenon without explaining it, and we may have potential explanations, or better correlations, that are not really understood.

We may speak more generally of quantitative research and its data to clarify what we see as an important distinction. The “raw data” that quantitative research—as an idealtypical activity, refers to is not available for further analysis; the numbers, once created, are not to be questioned (Franzosi 2016 : 138). If the researcher is to do “more” or “change” something, this will be done by conjectures based on theoretical knowledge or based on the researcher’s lifeworld. Both qualitative and quantitative research is based on the lifeworld, and all researchers use prejudices and pre-understanding in the research process. This idea is present in the works of Heidegger ( 2001 ) and Heisenberg (cited in Franzosi 2010 :619). Qualitative research, as we argued, involves the interaction and questioning of concepts (theory), data, and evidence.

Ragin ( 2004 :22) points out that “a good definition of qualitative research should be inclusive and should emphasize its key strengths and features, not what it lacks (for example, the use of sophisticated quantitative techniques).” We define qualitative research as an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied. Qualitative research, as defined here, is consequently a combination of two criteria: (i) how to do things –namely, generating and analyzing empirical material, in an iterative process in which one gets closer by making distinctions, and (ii) the outcome –improved understanding novel to the scholarly community. Is our definition applicable to our own study? In this study we have closely read the empirical material that we generated, and the novel distinction of the notion “qualitative research” is the outcome of an iterative process in which both deduction and induction were involved, in which we identified the categories that we analyzed. We thus claim to meet the first criteria, “how to do things.” The second criteria cannot be judged but in a partial way by us, namely that the “outcome” —in concrete form the definition-improves our understanding to others in the scientific community.

We have defined qualitative research, or qualitative scientific work, in relation to quantitative scientific work. Given this definition, qualitative research is about questioning the pre-given (taken for granted) variables, but it is thus also about making new distinctions of any type of phenomenon, for example, by coining new concepts, including the identification of new variables. This process, as we have discussed, is carried out in relation to empirical material, previous research, and thus in relation to theory. Theory and previous research cannot be escaped or bracketed. According to hermeneutic principles all scientific work is grounded in the lifeworld, and as social scientists we can thus never fully bracket our pre-understanding.

We have proposed that quantitative research, as an idealtype, is concerned with pre-determined variables (Small 2008 ). Variables are epistemically fixed, but can vary in terms of dimensions, such as frequency or number. Age is an example; as a variable it can take on different numbers. In relation to quantitative research, qualitative research does not reduce its material to number and variables. If this is done the process of comes to a halt, the researcher gets more distanced from her data, and it makes it no longer possible to make new distinctions that increase our understanding. We have above discussed the components of our definition in relation to quantitative research. Our conclusion is that in the research that is called quantitative there are frequent and necessary qualitative elements.

Further, comparative empirical research on researchers primarily working with ”quantitative” approaches and those working with ”qualitative” approaches, we propose, would perhaps show that there are many similarities in practices of these two approaches. This is not to deny dissimilarities, or the different epistemic and ontic presuppositions that may be more or less strongly associated with the two different strands (see Goertz and Mahoney 2012 ). Our point is nonetheless that prejudices and preconceptions about researchers are unproductive, and that as other researchers have argued, differences may be exaggerated (e.g., Becker 1996 : 53, 2017 ; Marchel and Owens 2007 :303; Ragin 1994 ), and that a qualitative dimension is present in both kinds of work.

Several things follow from our findings. The most important result is the relation to quantitative research. In our analysis we have separated qualitative research from quantitative research. The point is not to label individual researchers, methods, projects, or works as either “quantitative” or “qualitative.” By analyzing, i.e., taking apart, the notions of quantitative and qualitative, we hope to have shown the elements of qualitative research. Our definition captures the elements, and how they, when combined in practice, generate understanding. As many of the quotations we have used suggest, one conclusion of our study holds that qualitative approaches are not inherently connected with a specific method. Put differently, none of the methods that are frequently labelled “qualitative,” such as interviews or participant observation, are inherently “qualitative.” What matters, given our definition, is whether one works qualitatively or quantitatively in the research process, until the results are produced. Consequently, our analysis also suggests that those researchers working with what in the literature and in jargon is often called “quantitative research” are almost bound to make use of what we have identified as qualitative elements in any research project. Our findings also suggest that many” quantitative” researchers, at least to some extent, are engaged with qualitative work, such as when research questions are developed, variables are constructed and combined, and hypotheses are formulated. Furthermore, a research project may hover between “qualitative” and “quantitative” or start out as “qualitative” and later move into a “quantitative” (a distinct strategy that is not similar to “mixed methods” or just simply combining induction and deduction). More generally speaking, the categories of “qualitative” and “quantitative,” unfortunately, often cover up practices, and it may lead to “camps” of researchers opposing one another. For example, regardless of the researcher is primarily oriented to “quantitative” or “qualitative” research, the role of theory is neglected (cf. Swedberg 2017 ). Our results open up for an interaction not characterized by differences, but by different emphasis, and similarities.

Let us take two examples to briefly indicate how qualitative elements can fruitfully be combined with quantitative. Franzosi ( 2010 ) has discussed the relations between quantitative and qualitative approaches, and more specifically the relation between words and numbers. He analyzes texts and argues that scientific meaning cannot be reduced to numbers. Put differently, the meaning of the numbers is to be understood by what is taken for granted, and what is part of the lifeworld (Schütz 1962 ). Franzosi shows how one can go about using qualitative and quantitative methods and data to address scientific questions analyzing violence in Italy at the time when fascism was rising (1919–1922). Aspers ( 2006 ) studied the meaning of fashion photographers. He uses an empirical phenomenological approach, and establishes meaning at the level of actors. In a second step this meaning, and the different ideal-typical photographers constructed as a result of participant observation and interviews, are tested using quantitative data from a database; in the first phase to verify the different ideal-types, in the second phase to use these types to establish new knowledge about the types. In both of these cases—and more examples can be found—authors move from qualitative data and try to keep the meaning established when using the quantitative data.

A second main result of our study is that a definition, and we provided one, offers a way for research to clarify, and even evaluate, what is done. Hence, our definition can guide researchers and students, informing them on how to think about concrete research problems they face, and to show what it means to get closer in a process in which new distinctions are made. The definition can also be used to evaluate the results, given that it is a standard of evaluation (cf. Hammersley 2007 ), to see whether new distinctions are made and whether this improves our understanding of what is researched, in addition to the evaluation of how the research was conducted. By making what is qualitative research explicit it becomes easier to communicate findings, and it is thereby much harder to fly under the radar with substandard research since there are standards of evaluation which make it easier to separate “good” from “not so good” qualitative research.

To conclude, our analysis, which ends with a definition of qualitative research can thus both address the “internal” issues of what is qualitative research, and the “external” critiques that make it harder to do qualitative research, to which both pressure from quantitative methods and general changes in society contribute.

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Acknowledgements

Financial Support for this research is given by the European Research Council, CEV (263699). The authors are grateful to Susann Krieglsteiner for assistance in collecting the data. The paper has benefitted from the many useful comments by the three reviewers and the editor, comments by members of the Uppsala Laboratory of Economic Sociology, as well as Jukka Gronow, Sebastian Kohl, Marcin Serafin, Richard Swedberg, Anders Vassenden and Turid Rødne.

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  • http://orcid.org/0000-0003-4808-3880 Andrew Booth 1 , 2 ,
  • Isolde Sommer 3 , 4 ,
  • Jane Noyes 2 , 5 ,
  • Catherine Houghton 2 , 6 ,
  • Fiona Campbell 1 , 7
  • The Cochrane Rapid Reviews Methods Group and Cochrane Qualitative and Implementation Methods Group (CQIMG)
  • 1 EnSyGN Sheffield Evidence Synthesis Group , University of Sheffield , Sheffield , UK
  • 2 Cochrane Qualitative and Implementation Methods Group (CQIMG) , London , UK
  • 3 Department for Evidence-based Medicine and Evaluation , University for Continuing Education Krems , Krems , Austria
  • 4 Cochrane Rapid Reviews Group & Cochrane Austria , Krems , Austria
  • 5 Bangor University , Bangor , UK
  • 6 University of Galway , Galway , Ireland
  • 7 University of Newcastle upon Tyne , Newcastle upon Tyne , UK
  • Correspondence to Professor Andrew Booth, Univ Sheffield, Sheffield, UK; a.booth{at}sheffield.ac.uk

This paper forms part of a series of methodological guidance from the Cochrane Rapid Reviews Methods Group and addresses rapid qualitative evidence syntheses (QESs), which use modified systematic, transparent and reproducible methodsu to accelerate the synthesis of qualitative evidence when faced with resource constraints. This guidance covers the review process as it relates to synthesis of qualitative research. ‘Rapid’ or ‘resource-constrained’ QES require use of templates and targeted knowledge user involvement. Clear definition of perspectives and decisions on indirect evidence, sampling and use of existing QES help in targeting eligibility criteria. Involvement of an information specialist, especially in prioritising databases, targeting grey literature and planning supplemental searches, can prove invaluable. Use of templates and frameworks in study selection and data extraction can be accompanied by quality assurance procedures targeting areas of likely weakness. Current Cochrane guidance informs selection of tools for quality assessment and of synthesis method. Thematic and framework synthesis facilitate efficient synthesis of large numbers of studies or plentiful data. Finally, judicious use of Grading of Recommendations Assessment, Development and Evaluation approach for assessing the Confidence of Evidence from Reviews of Qualitative research assessments and of software as appropriate help to achieve a timely and useful review product.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Rapid Qualitative Evidence Synthesis (QES) is a relatively recent innovation in evidence synthesis and few published examples currently exists.

Guidance for authoring a rapid QES is scattered and requires compilation and summary.

WHAT THIS STUDY ADDS

This paper represents the first attempt to compile current guidance, illustrated by the experience of several international review teams.

We identify features of rapid QES methods that could be accelerated or abbreviated and where methods resemble those for conventional QESs.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

This paper offers guidance for researchers when conducting a rapid QES and informs commissioners of research and policy-makers what to expect when commissioning such a review.

Introduction

This paper forms part of a series from the Cochrane Rapid Reviews Methods Group providing methodological guidance for rapid reviews. While other papers in the series 1–4 focus on generic considerations, we aim to provide in-depth recommendations specific to a resource-constrained (or rapid) qualitative evidence synthesis (rQES). 5 This paper is accompanied by recommended resources ( online supplemental appendix A ) and an elaboration with practical considerations ( online supplemental appendix B ).

Supplemental material

The role of qualitative evidence in decision-making is increasingly recognised. 6 This, in turn, has led to appreciation of the value of qualitative evidence syntheses (QESs) that summarise findings across multiple contexts. 7 Recognition of the need for such syntheses to be available at the time most useful to decision-making has, in turn, driven demand for rapid qualitative evidence syntheses. 8 The breadth of potential rQES mirrors the versatility of QES in general (from focused questions to broad overviews) and outputs range from descriptive thematic maps through to theory-informed syntheses (see table 1 ).

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Glossary of important terms (alphabetically)

As with other resource-constrained reviews, no one size fits all. A team should start by specifying the phenomenon of interest, the review question, 9 the perspectives to be included 9 and the sample to be determined and selected. 10 Subsequently, the team must finalise the appropriate choice of synthesis. 11 Above all, the review team should consider the intended knowledge users, 3 including requirements of the funder.

An rQES team, in particular, cannot afford any extra time or resource requirements that might arise from either a misunderstanding of the review question, an unclear picture of user requirements or an inappropriate choice of methods. The team seeks to align the review question and the requirements of the knowledge user with available time and resources. They also need to ensure that the choice of data and choice of synthesis are appropriate to the intended ‘knowledge claims’ (epistemology) made by the rQES. 11 This involves the team asking ‘what types of data are meaningful for this review question?’, ‘what types of data are trustworthy?’ and ‘is the favoured synthesis method appropriate for this type of data?’. 12 This paper aims to help rQES teams to choose methods that best fit their project while understanding the limitations of those choices. Our recommendations derive from current QES guidance, 5 evidence on modified QES methods, 8 13 and practical experience. 14 15

This paper presents an overview of considerations and recommendations as described in table 2 . Supplemental materials including additional resources details of our recommendations and practical examples are provided in online supplemental appendices A and B .

Recommendations for resource-constrained qualitative evidence synthesis (rQES)

Setting the review question and topic refinement

Rapid reviews summarise information from multiple research studies to produce evidence for ‘the public, researchers, policymakers and funders in a systematic, resource-efficient manner’. 16 Involvement of knowledge users is critical. 3 Given time constraints, individual knowledge users could be asked only to feedback on very specific decisions and tasks or on selective sections of the protocol. Specifically, whenever a QES is abbreviated or accelerated, a team should ensure that the review question is agreed by a minimum number of knowledge users with expertise or experience that reflects all the important review perspectives and with authority to approve the final version 2 5 11 ( table 2 , item R1).

Involvement of topic experts can ensure that the rQES is responsive to need. 14 17 One Cochrane rQES saved considerable time by agreeing the review topic within a single meeting and one-phase iteration. 9 Decisions on topics to be omitted are also informed by a knowledge of existing QESs. 17

An information specialist can help to manage the quantity and quality of available evidence by setting conceptual boundaries and logistic limits. A structured question format, such as Setting-Perspective-Interest, phenomenon of-Comparison-Evaluation or Population-Interest, phenomenon of-Context helps in communicating the scope and, subsequently, in operationalising study selection. 9 18

Scoping (of review parameters) and mapping (of key types of evidence and likely richness of data) helps when planning the review. 5 19 The option to choose purposive sampling over comprehensive sampling approaches, as offered by standard QES, may be particularly helpful in the context of a rapid QES. 8 Once a team knows the approximate number and distribution of studies, perhaps mapping them against country, age, ethnicity, etc), they can decide whether or not to use purposive sampling. 12 An rQES for the WHO combined purposive with variation sampling. Sampling in two stages started by reducing the initial number of studies to a more manageable sampling frame and then sampling approximately a third of the remaining studies from within the sampling frame. 20

Sampling may target richer studies and/or privilege diversity. 8 21 A rich qualitative study typically illustrates findings with verbatim extracts from transcripts from interviews or textual responses from questionnaires. Rich studies are often found in specialist qualitative research or social science journals. In contrast, less rich studies may itemise themes with an occasional indicative text extract and tend to summarise findings. In clinical or biomedical journals less rich findings may be placed within a single table or box.

No rule exists on an optimal number of studies; too many studies makes it challenging to ‘maintain insight’, 22 too few does not sustain rigorous analysis. 23 Guidance on sampling is available from the forthcoming Cochrane-Campbell QES Handbook.

A review team can use templates to fast-track writing of a protocol. The protocol should always be publicly available ( table 2 , item R2). 24 25 Formal registration may require that the team has not commenced data extraction but should be considered if it does not compromise the rQES timeframe. Time pressures may require that methods are left suitably flexible to allow well-justified changes to be made as a detailed picture of the studies and data emerge. 26 The first Cochrane rQES drew heavily on text from a joint protocol/review template previously produced within Cochrane. 24

Setting eligibility criteria

An rQES team may need to limit the number of perspectives, focusing on those most important for decision-making 5 9 27 ( table 2 , item R3). Beyond the patients/clients each additional perspective (eg, family members, health professionals, other professionals, etc) multiplies the additional effort involved.

A rapid QES may require strict date and setting restrictions 17 and language restrictions that accommodate the specific requirements of the review. Specifically, the team should consider whether changes in context over time or substantive differences between geographical regions could be used to justify a narrower date range or a limited coverage of countries and/or languages. The team should also decide if ‘indirect evidence’ is to substitute for the absence of direct evidence. An rQES typically focuses on direct evidence, except when only indirect evidence is available 28 ( table 2 , item R4). Decisions on relevance are challenging—precautions for swine influenza may inform precautions for bird influenza. 28 A smoking ban may operate similarly to seat belt legislation, etc. A review team should identify where such shared mechanisms might operate. 28 An rQES team must also decide whether to use frameworks or models to focus the review. Theories may be unearthed within the topic search or be already known to team members, fro example, Theory of Planned Behaviour. 29

Options for managing the quantity and quality of studies and data emerge during the scoping (see above). In summary, the review team should consider privileging rich qualitative studies 2 ; consider a stepwise approach to inclusion of qualitative data and explore the possibility of sampling ( table 2 , item R5). For example, where data is plentiful an rQES may be limited to qualitative research and/or to mixed methods studies. Where data is less plentiful then surveys or other qualitative data sources may need to be included. Where plentiful reviews already exist, a team may decide to conduct a review of reviews 5 by including multiple QES within a mega-synthesis 28 29 ( table 2 , item R6).

Searching for QES merits its own guidance, 21–23 30 this section reinforces important considerations from guidance specific to qualitative research. Generic guidance for rapid reviews in this series broadly applies to rapid QESs. 1

In addition to journal articles, by far the most plentiful source, qualitative research is found in book chapters, theses and in published and unpublished reports. 21 Searches to support an rQES can (a) limit the number of databases searched, deliberately selecting databases from diverse disciplines, (b) use abbreviated study filters to retrieve qualitative designs and (c) employ high yield complementary methods (eg, reference checking, citation searching and Related Articles features). An information specialist (eg, librarian) should be involved in prioritising sources and search methods ( table 2 , item R7). 11 14

According to empirical evidence optimal database combinations include Scopus plus CINAHL or Scopus plus ProQuest Dissertations and Theses Global (two-database combinations) and Scopus plus CINAHL plus ProQuest Dissertations and Theses Global (three-database combination) with both choices retrieving between 89% and 92% of relevant studies. 30

If resources allow, searches should include one or two specialised databases ( table 2 , item R8) from different disciplines or contexts 21 (eg, social science databases, specialist discipline databases or regional or institutional repositories). Even when resources are limited, the information specialist should factor in time for peer review of at least one search strategy ( table 2 , item R9). 31 Searches for ‘grey literature’ should selectively target appropriate types of grey literature (such as theses or process evaluations) and supplemental searches, including citation chaining or Related Articles features ( table 2 , item R10). 32 The first Cochrane rQES reported that searching reference lists of key papers yielded an extra 30 candidate papers for review. However, the team documented exclusion of grey literature as a limitation of their review. 15

Study selection

Consistency in study selection is achieved by using templates, by gaining a shared team understanding of the audience and purpose, and by ongoing communication within, and beyond, the team. 2 33 Individuals may work in parallel on the same task, as in the first Cochrane rQES, or follow a ‘segmented’ approach where each reviewer is allocated a different task. 14 The use of machine learning in the specific context of rQES remains experimental. However, the possibility of developing qualitative study classifiers comparable to those for randomised controlled trials offers an achievable aspiration. 34

Title and abstract screening

The entire screening team should use pre-prepared, pretested title and abstract templates to limit the scale of piloting, calibration and testing ( table 2 , item R11). 1 14 The first Cochrane rQES team double-screened titles and abstracts within Covidence review software. 14 Disagreements were resolved with reference to a third reviewer achieving a shared understanding of the eligibility criteria and enhancing familiarity with target studies and insight from data. 14 The team should target and prioritise identified risks of either over-zealous inclusion or over-exclusion specific to each rQES ( table 2 , item R12). 14 The team should maximise opportunities to capture divergent views and perspectives within study findings. 35

Full-text screening

Full-text screening similarly benefits from using a pre-prepared pretested standardised template where possible 1 14 ( table 2 , item R11). If a single reviewer undertakes full-text screening, 8 the team should identify likely risks to trustworthiness of findings and focus quality control procedures (eg, use of additional reviewers and percentages for double screening) on specific threats 14 ( table 2 , item R13). The Cochrane rQES team opted for double screening to assist their immersion within the topic. 14

Data extraction

Data extraction of descriptive/contextual data may be facilitated by review management software (eg, EPPI-Reviewer) or home-made approaches using Google Forms, or other survey software. 36 Where extraction of qualitative findings requires line-by-line coding with multiple iterations of the data then a qualitative data management analysis package, such as QSR NVivo, reaps dividends. 36 The team must decide if, collectively, they favour extracting data to a template or coding direct within an electronic version of an article.

Quality control must be fit for purpose but not excessive. Published examples typically use a single reviewer for data extraction 8 with use of two independent reviewers being the exception. The team could limit data extraction to minimal essential items. They may also consider re-using descriptive details and findings previously extracted within previous well-conducted QES ( table 2 , item R14). A pre-existing framework, where readily identified, may help to structure the data extraction template. 15 37 The same framework may be used to present the findings. Some organisations may specify a preferred framework, such as an evidence-to-decision-making framework. 38

Assessment of methodological limitations

The QES community assess ‘methodological limitations’ rather than use ‘risk of bias’ terminology. An rQES team should pick an approach appropriate to their specific review. For example, a thematic map may not require assessment of individual studies—a brief statement of the generic limitations of the set of studies may be sufficient. However, for any synthesis that underpins practice recommendations 39 assessment of included studies is integral to the credibility of findings. In any decision-making context that involves recommendations or guidelines, an assessment of methodological limitations is mandatory. 40 41

Each review team should work with knowledge users to determine a review-specific approach to quality assessment. 27 While ‘traffic lights’, similar to the outputs from the Cochrane Risk of Bias tool, may facilitate rapid interpretation, accompanying textual notes are invaluable in highlighting specific areas for concern. In particular, the rQES team should demonstrate that they are aware (a) that research designs for qualitative research seek to elicit divergent views, rather than control for variation; (b) that, for qualitative research, the selection of the sample is far more informative than the size of the sample; and (c) that researchers from primary research, and equally reviewers for the qualitative synthesis, need to be thoughtful and reflexive about their possible influences on interpretation of either the primary data or the synthesised findings.

Selection of checklist

Numerous scales and checklists exist for assessing the quality of qualitative studies. In the absence of validated risk of bias tools for qualitative studies, the team should choose a tool according to Cochrane Qualitative and Implementation Methods Group (CQIMG) guidance together with expediency (according to ease of use, prior familiarity, etc) ( table 2 , item R15). 41 In comparison to the Critical Appraisal Skills Programme checklist which was never designed for use in synthesis, 42 the Cochrane qualitative tool is similarly easy to use and was designed for QES use. Work is underway to identify an assessment process that is compatible with QESs that support decision-making. 41 For now the choice of a checklist remains determined by interim Cochrane guidance and, beyond this, by personal preference and experience. For an rQES a team could use a single reviewer to assess methodological limitations, with verification of judgements (and support statements) by a second reviewer ( table 2 , item R16).

The CQIMG endorses three types of synthesis; thematic synthesis, framework synthesis and meta-ethnography ( box 1 ). 43 44 Rapid QES favour descriptive thematic synthesis 45 or framework synthesis, 46 47 except when theory generation (meta-ethnography 48 49 or analytical thematic synthesis) is a priority ( table 2 , item R17).

Choosing a method for rapid qualitative synthesis

Thematic synthesis: first choice method for rQES. 45 For example, in their rapid QES Crooks and colleagues 44 used a thematic synthesis to understand the experiences of both academic and lived experience coresearchers within palliative and end of life research. 45

Framework synthesis: alternative where a suitable framework can be speedily identified. 46 For example, Bright and colleagues 46 considered ‘best-fit framework synthesis’ as appropriate for mapping study findings to an ‘a priori framework of dimensions measured by prenatal maternal anxiety tools’ within their ‘streamlined and time-limited evidence review’. 47

Less commonly, an adapted meta-ethnographical approach was used for an implementation model of social distancing where supportive data (29 studies) was plentiful. 48 However, this QES demonstrates several features that subsequently challenge its original identification as ‘rapid’. 49

Abbrevations: QES, qualitative evidence synthesis; rQES, resource-constrained qualitative evidence synthesis.

The team should consider whether a conceptual model, theory or framework offers a rapid way for organising, coding, interpreting and presenting findings ( table 2 , item R18). If the extracted data appears rich enough to sustain further interpretation, data from a thematic or framework synthesis can subsequently be explored within a subsequent meta-ethnography. 43 However, this requires a team with substantial interpretative expertise. 11

Assessments of confidence in the evidence 4 are central to any rQES that seeks to support decision-making and the QES-specific Grading of Recommendations Assessment, Development and Evaluation approach for assessing the Confidence of Evidence from Reviews of Qualitative research (GRADE-CERQual) approach is designed to assess confidence in qualitative evidence. 50 This can be performed by a single reviewer, confirmed by a second reviewer. 26 Additional reviewers could verify all, or a sample of, assessments. For a rapid assessment a team must prioritise findings, using objective criteria; a WHO rQES focused only on the three ‘highly synthesised findings’. 20 The team could consider reusing GRADE-CERQual assessments from published QESs if findings are relevant and of demonstrable high quality ( table 2 , item R19). 50 No rapid approach to full application of GRADE-CERQual currently exists.

Reporting and record management

Little is written on optimal use of technology. 8 A rapid review is not a good time to learn review management software or qualitative analysis management software. Using such software for all general QES processes ( table 2 , item R20), and then harnessing these skills and tools when specifically under resource pressures, is a sounder strategy. Good file labelling and folder management and a ‘develop once, re-use multi-times’ approach facilitates resource savings.

Reporting requirements include the meta-ethnography reporting guidance (eMERGe) 51 and the Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement. 52 An rQES should describe limitations and their implications for confidence in the evidence even more thoroughly than a regular QES; detailing the consequences of fast-tracking, streamlining or of omitting processes all together. 8 Time spent documenting reflexivity is similarly important. 27 If QES methodology is to remain credible rapid approaches must be applied with insight and documented with circumspection. 53 54 (56)

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

  • Data supplement 1

Contributors All authors (AB, IS, JN, CH, FC) have made substantial contributions to the conception and design of the guidance document. AB led on drafting the work and revising it critically for important intellectual content. All other authors (IS, JN, CH, FC) contributed to revisions of the document. All authors (AB, IS, JN, CH, FC) have given final approval of the version to be published. As members of the Cochrane Qualitative and Implementation Methods Group and/or the Cochrane Rapid Reviews Methods Group all authors (AB, IS, JN, CH, FC) agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests AB is co-convenor of the Cochrane Qualitative and Implementation Methods Group. In the last 36 months, he received royalties from Systematic Approaches To a Successful Literature Review (Sage 3rd edition), honoraria from the Agency for Healthcare Research and Quality, and travel support from the WHO. JN is lead convenor of the Cochrane Qualitative and Implementation Methods Group. In the last 36 months, she has received honoraria from the Agency for Healthcare Research and Quality and travel support from the WHO. CH is co-convenor of the Cochrane Qualitative and Implementation Methods Group.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; internally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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  • Perspect Clin Res
  • v.4(3); Jul-Sep 2013

Qualitative research

Vibha pathak.

Department of Clinical Research, Bharti Hospital and BRIDE, Karnal, Haryana, India

Bijayini Jena

1 Department of Nutrition, Bharti Hospital and BRIDE, Karnal, Haryana, India

Sanjay Kalra

2 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India

Scientific research is based upon finding a solution to a particular problem one can identify. There are various methods of formulating a research design for the study. Two broad approaches of data collection and interpretation in research are qualitative and quantitative research. The elementary method of conducting research was quantitative, but recently, qualitative method of research has also gained momentum among researchers.

Qualitative research focuses in understanding a research query as a humanistic or idealistic approach. Though quantitative approach is a more reliable method as it is based upon numeric and methods that can be made objectively and propagated by other researchers. Qualitative method is used to understand people's beliefs, experiences, attitudes, behavior, and interactions. It generates non-numerical data. The integration of qualitative research into intervention studies is a research strategy that is gaining increased attention across disciplines. Although once viewed as philosophically incongruent with experimental research, qualitative research is now recognized for its ability to add a new dimension to interventional studies that cannot be obtained through measurement of variables alone.[ 1 ] Qualitative research was initially used in psychological studies when researchers found it tedious to evaluate human behavior in numeric. Since then, qualitative research is used in other research fields as well. In clinical research, qualitative approach can help view the data more extensively. It strengthens clinical trials by enhancing user involvement in it.

Three broad categories of qualitative research of interest exists in clinical research: Observational studies, interview studies and documentary/textual analysis of various written records.[ 2 ] Qualitative research gives voice to the participants in the study.[ 1 ] It permits the participants to share their experiences of the effects of the drug of interest. This can open our eyes to new aspects of the study and help modify the design of the clinical trial. Qualitative study enhances the involvement of everyone related to the study. The researcher works on the social parameters in addition to the quantitative measures in the study. The subjects also have an empowering experience in the study. They have an active role in the study and can voice their individual benefits and harms of the study. In addition, with qualitative methods, the relationship between the researcher and the participant is often less formal than in quantitative research.

Qualitative research can have a major contribution in health research. In clinical trials, qualitative research can have a great impact on data collection, its analysis and the interpretation of results. Qualitative studies should be well-designed and the aims, procedures of the study should be meticulously adjudicated. Study should have pre-determined methods to nullify research bias. When combined with quantitative measures, qualitative study can give a better understanding of health related issues. The perspectives in clinical research should highlight advances in qualitative research as well, to optimize quality and utility of this method of research.

  • Open access
  • Published: 09 February 2024

The ebbs and flows of empathy: a qualitative study of surgical trainees in the UK

  • Pranathi Yannamani 1 &
  • Nicola Kay Gale 2  

BMC Medical Education volume  24 , Article number:  131 ( 2024 ) Cite this article

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Empathy is widely recognised as an important element of medical practice contributing to patient outcomes and satisfaction. It is also an important element of collaborative work in a healthcare team. However, there is evidence to suggest that empathy towards patients declines over time, particularly in surgical specialities. There is little qualitative research on this decline in surgical trainees, particularly in the UK. Therefore, the aim of this study was to explore how trainee surgeons experience empathy over the course of their career, both towards patients and colleagues and how they perceive it in others.

10 semi-structured interviews were carried out with surgical trainees of different grades and specialties in January and February 2022. Framework analysis was used to interpret the data.

Participants experienced an evolution in empathy over their career as their personal and professional experience was added to. They drew a distinction between desensitisation and actual decline in empathy and identified more with experiencing the former in their careers. Participants also felt interprofessional relationships require empathy, and this could be improved upon. Finally, they highlighted specific impacts of the COVID-19 pandemic upon their training, including reduced theatre time.

Conclusions

Participants felt training could be improved in regard to accessing training opportunities and relationships with colleagues, although many felt empathy between colleagues is better than it has been in the past. This project highlighted areas for future research, such as with surgeons in later stages of their careers, or mixed-methods projects.

Peer Review reports

Empathy in medical practice- for patients and colleagues

Empathy is an important factor in the way doctors practise medicine, as increased physician empathy has been shown to improve patient outcomes and satisfaction [ 1 ]. Physician empathy also reduces patient anxiety and increases their understanding and ability to cope with their condition [ 2 ]. In fact, regardless of the therapeutic context, empathy has been shown to foster communication between the healthcare professional and the patient, empower the patient and help resolve the patient’s problems [ 3 ]. The importance of empathy in medical education is recognised as it is a required component of medical training in the United Kingdom and the United States [ 4 , 5 ].

While there is not one single definition of clinical empathy due to its ambiguity as a concept, a concise summary is psychologist Carl Rogers’ definition: “to sense the client’s private world as if it were your own, but without losing the ‘as if’ quality” [ 6 ].

In addition to empathy towards patients, interprofessional empathy is being increasingly recognised as important in collaborative patient care, but this link is less discussed in the literature [ 7 ]. Furthermore, studies have suggested that interprofessional relationships in healthcare are often characterised by hostility and conflict rather than cooperation [ 10 , 11 , 12 , 11 ]. Empathy towards colleagues is a little-researched area, despite teamwork being one of the foundational principles upon which healthcare works and empathy being a key component of teamwork [ 12 ].

Empathy decline in surgeons

Much research has been conducted that shows a decline in empathy in medical students, beginning in their first year of clinical placement and continuing through medical training [ 15 , 16 , 17 , 18 , 17 ]. This decline in empathy is also associated with an increase in cynicism and emotional detachment [ 18 ].

The reasons for the empathy decline are unclear but influencing factors include discrimination or mistreatment by superiors, social support problems and a high workload [ 17 ]. These are examples of the ‘hidden curriculum’, influences that exist outside the official medical school curriculum and teaching but are nevertheless important to learn. As Hafferty describes them, “commonly held “understandings”, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education” [ 19 ].

Students favouring technology-oriented specialties, or “patient-remote” specialties (e.g., surgery, radiology) had lower empathy scores than those favouring specialties with more patient interaction [ 17 , 20 ]. The classification of certain specialties as ‘patient-remote’ in this literature is subjective, as there is arguably a significant amount of patient contact in surgical specialties. There is also research suggesting the empathy decline is more severe in surgery than in medicine, highlighting a potential need for empathy training [ 21 ]. Furthermore, surgeon empathy, as rated by patients, is the strongest motivator of patient satisfaction [ 22 ]. However, a 2008 study of orthopaedic surgeons’ consultations showed that patients only raised around half of their concerns with their surgeons, rarely raising social issues [ 23 ]. This could be due to surgeons missing cues given by patients, or a blinkered focus on the biomedical aspects of patient care [ 23 , 24 ]. Furthermore, a 2015 public enquiry reported that more empathy is required in the NHS, since a lack of empathy led to failings in patient care in the Mid-Staffordshire Foundation Trust [ 25 ].

There is qualitative research into patient perceptions of surgeon empathy, but research with less of a focus on patient interactions and outcomes is needed [ 23 , 26 ]. Indeed, the patient perspective is invaluable, but without knowledge of the practitioners’ thoughts and feelings, service improvement for the benefit of both staff and patients would not be possible.

Study rationale

While there is literature demonstrating the decline in empathy, particularly in surgeons and its impact on patient care, there is little qualitative research on clinicians’ perceptions of this decline in empathy, or its perceived impact of this upon their practice. Furthermore, a large portion of the empathy research has taken place in the USA where there are important differences in medical practice compared to the UK, such as the funding system [ 28 , 29 , 30 , 31 , 32 , 31 ]. The qualitative research that has been done into empathy in surgery is also predominantly US-based and focuses on patient outcomes rather than practitioner perceptions or interprofessional relationships [ 22 , 23 , 26 ].

Additionally, most of the empathy research focusses on practitioners’ empathy towards patients, rather than for their colleagues. Little of the research on empathy in the UK focusses on surgical trainees, particularly in the form of interviews [ 32 ].

In the context of the NHS’ staffing crisis and high rates of attrition of doctors, this information could prove invaluable in practice as well as filling a crucial gap in the research [ 33 ]. Significant points of attrition of doctors include consultants retiring early and no longer opting to do extra sessions they used to in the past, and many medical students planning to work outside of the UK once qualified [ 34 ]. The COVID-19 pandemic put increased strain on already pressurised areas of the National Health Service, such as staffing shortages and increasing workload, as well as relationships between colleagues [ 35 ].

Qualitative insights into surgical culture are limited, as quantitative methods are often favoured in surgical research, and medical research more widely. The BMJ recently shared its stance on qualitative research as ‘low priority’, as these articles were less frequently accessed and cited, much to the dismay of many qualitative and mixed-methods researchers and others who had argued over many years of the important of understanding the value of systematic exploration of social, political and psychological issues in the training, delivery and organisation of health care [ 36 , 37 ].

This research project aims to complement a growing body of quantitative information with qualitative insights that shed light on individual experiences and perceptions of empathy over the course of their career towards patients and between colleagues.

Research design and ethics

A qualitative study design was adopted, to explore the perceptions and experience of empathy for surgeons at different stages of training and to allow for inductive, interpretative analysis, which disputes the concept of a singular truth [ 38 ] but acknowledges the real-life impact of different subjective perspectives on social interaction and outcomes. Therefore, this research contributes to the wider field of interdisciplinary empathy research. Ethical approval was granted by the School of Liberal Arts and Natural Sciences ethics committee at the University of Birmingham in accordance with the University code of practice on research.

Participants

To answer the research questions, surgical trainees were chosen because they have had experience working in surgical departments as a surgeon, but they are still in the midst of their training. In the UK, medical graduates complete 2 years of rotational foundation training, regardless of their desired specialty. The route to specialise in surgery is as follows: following completion of foundation training, they will enter core surgical training which consists of 2 years of rotational training through surgical specialties only. These are known as core surgical training year 1 (CT1) and core surgical training year 2 (CT2). Following this, they will enter specialty training (ST) which lasts approximately 6 years. After completion of specialty training, they receive a certificate of completion of training (CCT) and become a consultant surgeon [ 38 ].

The inclusion criteria were: participants were surgical trainees (CT1-2/ST1-ST8) in the UK NHS; they must have not yet achieved their CCT; they could be in an out-of-training job but must have commenced CT1 or ST1 and have plans to return to training, and they could be based anywhere in the UK.

Recruitment

The study flyer was disseminated on social media and via email to all surgical trainees on the West Midlands Deanery mailing list (which included a number of people who had since moved to other roles elsewhere in the country). The total number of surgical trainees in the West Midlands Deanery is approximately 500 [ 39 ]. Potential participants were asked to email the researcher for more information, before being asked for informed written or verbal consent to participate. Informed consent was obtained from all participants. No incentive was provided to participate, and recruitment stopped when data saturation occurred ( n  = 10).

Initially a purposive approach was used, with the intention of recruiting a range of trainees of different ages, genders, and ethnicities to the study. However, to meet the recruitment target (reaching saturation), further snowball sampling was used (asking participants to recommend others, particularly those whose views might differ from their own). Finally, the study consisted of ten semi-structured interviews.

Data collection

A topic guide was used and was used flexibly to allow for participants to raise unforeseen issues, as well as for the researcher to be able to adapt questioning based upon the participants’ comments. A pilot interview was carried out with a medical student, to test the answerability of the questions and whether they made sense to a clinical audience, but no substantial changes were required following this. The interviews lasted around 60 min and were digitally video recorded and transcribed by the researcher. Transcripts were anonymised prior to analysis.

Data analysis

An inductive approach to analysis was used so that the themes were generated from the data, rather than being informed by prior theory. The Framework method for the analysis of qualitative data was used, which is a form of thematic analysis [ 40 ]. In line with inductive qualitative analysis principles, analysis took place alongside data collection, so that analysis could inform future interviews in an iterative process. All transcripts were coded by the first author, a medical student, and a lay person to facilitate and triangulate interpretations. Coded data were inputted into the Framework matrix and analytic memos were prepared for each emergent theme. These were discussed and debated with the second author, a social science researcher, prior to finalising themes.

Four main themes were identified in the data. The first was that being empathetic was a question of balance, the second was that the way an individual experiences empathy changes over their career (and is not always a decline), the third was that coping with COVID-19 has amplified aspects of team working, and the final theme was the view that generational change has resulted in societal changes in empathy perception. No new themes were emerging after ten interviews and Table  1 summarises the participants.

Evolution of empathy in the individual: being empathic was a question of balance

Holism vs. efficiency.

Participants all stated empathy was important in treating patients and often had a positive impact upon patient care. Many stated that part of empathising with their patients was understanding what was important to them and their families.

If you don’t understand what’s important to your patient, you will never be able to help them fully. - P8

Participants highlighted holism in the need to respect patient autonomy over paternalism and emphasized that getting to know their patients was crucial to identifying the best treatment option.

Actually, we’re here to treat you and, therefore, you should have a say in what we do to you. And that is absolutely correct- P2

The conflict between efficiency and comprehensive care was also mentioned by some participants. While they acknowledged the importance of empathy in treating patients, high volumes of patients and under-staffing can result in less time spent with patients and therefore the prioritisation of their clinical condition.

I saw like 46 patients in one twelve-hour shift. It’s just like fine just tell me, presenting complaint, like just running through the history, not really caring about what the patient says it’s more of just yes, no have you got these positive symptoms- P9

Objectivity vs. subjectivity

While participants all agreed that empathy was invaluable in treating patients, they suggested it was possible to empathise too much, and this could have negative implications for both the practitioner and patient. Participants also mentioned being criticised for showing emotions at work. This suggests a discomfort from colleagues towards demonstrating emotion in the surgical environment.

I have also received personal criticism for being too caring with my patients, for being too interested in what they have to say and for showing emotion when something… has affected me- P4

Other participants suggested that it was possible to focus too much on empathy and lose surgical quality. This indicates an implicit association between having a theoretical excess of empathy and deficiency in surgical skill, which is based on a binary system where empathy is compared to technical skill. This association may affect how people feel their colleagues perceive their surgical competence. This demonstrates an area where empathy between colleagues could be beneficial to making people feel less judged.

If you go too far the other way and make it all about empathy but then lose some aspects of surgical quality that’s also wrong- P3

Other participants saw being able to ‘switch off’ empathy as necessary to being effective in surgery, because being distracted by non-surgical factors can cloud one’s judgement. Participant 5 works in paediatric surgery, where the evidence base is limited, so the surgeons’ clinical decisions often take precedence [ 41 ]. In these situations, the participant stated it is important not to let emotions impact treatment decisions.

you have to have the ability to be focused on surgery to be able to be objective, to be able to make good decisions… without feeling bad about yourself for making someone intentionally worse with the aim of making them better-P5

Therefore, there are three primary reasons participants cited for needing to remain as objective as possible and not empathising ‘too much’: intrinsic depletion of emotional resources, contamination of the patient’s plan with one’s own emotions and fear of criticism by colleagues. These are both intrinsic and extrinsic reasons.

The Team vs. the individual

Participants mentioned trying to be empathetic towards patients can result in negative impacts upon the team, demonstrating the delicate balance between looking after patients, and being considerate towards colleagues.

if I give too much time to one patient then the whole department could lose their lunch break- P6

They highlighted the competitive nature of surgery and how this contrasts with the need to work in a team, which can affect working relationships. Participants stated it is sometimes difficult to ask for help from colleagues as they would be talked about or perceived as less competent; this dynamic undermines team working.

we need to try and remove some of the competitive nature of specialty training… Because you know you can’t show anybody else if you were struggling with a particular aspect of your training it’s seen as a weakness- P7

Empathy changes over career

Participants spoke of how the way they empathise with patients has changed over their years of practice. Here, this qualitative evidence paints a more complex picture than the previous quantitative data, which simply shows a decline in empathy over time. Participants cited two reasons for this change: experience with patients at work and experience in their personal life. For example, some participants became parents over the course of their training, and that has changed the way they understand the way paediatric patients’ parents feel. Other participants, who had experiences with illness in their personal lives described feeling more emotionally impacted when they see patients who remind them of this situation.

I see myself as able to empathize with that parent because I’m also a parent- P3

However, participants associated increased experience of the job with becoming desensitised. The desensitisation was not always associated with a decrease in empathy, though it was for some participants. Participants did not think the clinical care they provided was made worse by this change, and in fact felt it was beneficial as it would be unsustainable to be deeply emotionally affected by every patient.

I get less personally upset by seeing bad things happen to patients but I’m still able to empathize with them and their family.- P3

Here we can see it is not simply a question of empathy declining, but of it evolving over the course of an individual’s career.

Evolution of empathy in response to extreme events: coping with COVID-19 has amplified the positive and negative

Participants also discussed how the COVID-19 pandemic specifically had an impact upon their wellbeing at work and ability to empathise with patients. Most participants referred to burnout and how the pandemic had worsened this. They referred to the impact of not having respite from continuous work throughout the pandemic, but also the psychological burden of being seemingly undervalued. This was compounded by the trauma of what participants saw during the pandemic.

…burnt out as a consequence of untapped care being poured out, with no reward no relief- P5

However, one participant identified that at her hospital, teamwork improved during the pandemic as everyone came together with a shared understanding of what their colleagues were going through.

The teamwork was the best it’s ever been it was very, especially at the start of the pandemic, It was almost like people were being very supportive to one another being very kind to one another- P7

Other participants felt COVID has a negative impact upon teamwork as staff absence due to COVID infection put a strain on the rest of the team.

More often recently, you know we’ve had absences in the team it’s very easy for in a poor team culture to start blaming those absences- P2

Furthermore, many trainees experienced vastly reduced opportunities to gain operating experience in theatre due to redeployment, the cancelling of elective surgeries, and the reduced number of surgeries that can be carried out in a day because of COVID cleaning procedures. Participants stated this had a negative impact upon their training, with some participants stating it increased competitiveness between colleagues further.

what COVID has done is that because there’s been a year and a half, lack of elective and also emergency theatres, trainees have become a lot more cutthroat-P10

Generational evolution of empathy

Participants stated there was a generational change in the attitudes of doctors, particularly seniors towards patients and colleagues. They observed a shift from more paternalistic, authoritarian views towards a more flexible, tolerant one.

at the beginning of my training when I would see seniors or juniors, for example, not necessarily consenting patients thoroughly before intimate examinations- P3

Participants noted that newer consultants who are qualifying are more empathetic than their predecessors.

there is a definite change in terms of younger consultants who are more accepting and empathetic that seems to be a better trend.-P4

Some participants attributed this change to an alteration in the types of people favoured in surgical selection. While previously interpersonal skills were not necessarily valued in surgical selection, they are now being weighted more heavily.

you’re going into surgery, because you think that you can be a bully you know, then you’re not going to get very far anymore.- P7 We are now looking for consultants who will mentor, educate, and support their juniors.- P8

Some participants linked this change in desirable attributes to a general societal change whereby people are becoming more empathetic towards one another. This shows that as well as a change in empathy over an individual’s career and life, societal change can impact the way people empathise on a generational level.

The world has become more sensitive to people’s needs and the importance of, for example, mental health- P4

While participants associated more progressive attitudes in medicine and surgery with a general societal change, others were not convinced, and saw changes within surgery as more superficial and performative.

I hear sexist comments a lot when women aren’t around… It’s like oh thank God she’s gone, like you know at least you can hold the camera steady- P9

Participants did feel sexist and racist attitudes prevailed, but in a more subtle way than they might have been in the past (although the above quote may not be considered so). Both male and female participants highlighted this, but male participants seemed to be privy to sexist comments as participants suggested the perpetrators are aware this behaviour is inappropriate, and therefore try to conceal it.

Furthermore, other participants commented on racist behaviour they had witnessed or been the target of, further suggesting that discrimination in medicine and surgery is far from gone.

I’m Chinese and there was a lot of anti-Chinese sentiment during COVID so there was a lot of abuse, aggression and I had colleagues that were also a little bit abusive as well- P6

While the participant quoted above describes explicit racism, participants also described witnessing racism in the form of microaggressions, and conflicts where an individual’s race may have played a part in how they were treated. The below quotation reflects a reluctance to name racism as a factor in workplace conflicts alongside an awareness that it could be.

I don’t think race was involved, so I don’t want to delve into that, I don’t think it was involved, but you never know- P1

The very generation of qualitative research on the experience of surgical trainees in the UK is novel, since they are a previously unresearched study population using qualitative methodology in the UK. This research contributes experiences of a change in empathy towards patients, rather than a specific decline among UK surgeons, as well as their experiences of interprofessional empathy. Further contributions include the impact of the COVID 19 pandemic on relationships within the medical team and on training opportunities.

Empathy towards patients evolves over time and experience

The most commonly used tool for measuring empathy is the Jefferson Scale of Empathy (JSE) questionnaire. As mentioned above in Empathy Decline in Surgeons , the JSE shows a decline in empathy in doctors over their careers [ 15 , 16 , 17 , 18 , 17 ]. The JSE has been validated in multiple ways [ 28 , 42 ]. While JSE responses show strong evidence for a decline in empathy, it is unclear whether the questionnaire captures the distinction between desensitisation and an actual decline in empathy. Additionally, the JSE does not provide explanations for why doctors and medical students feel less empathetic towards patients, which limits the data’s utility.

Empathy towards patients was not seen as lacking overall by participants, and this could be because participants experienced a change in empathy towards patients rather than a decline in it, as quantitative data suggests. While participants referred to a desensitisation that occurs over the course of their careers, many of them explicitly said that they feel more empathy towards patients now than they did earlier in their careers, because of more life experience and experience with patients, as well as feeling they have a more significant role in the patient’s care. Furthermore, participants described the need to disconnect somewhat while undertaking surgery, because they are ultimately causing physical trauma to the patient with risks involved. This is supported in Han and Pappas’s paper which describes how surgeons need a ‘self-defence’ mechanism in the face of the traumatic nature of their healing [ 21 ]. They also discuss a “distinctly surgical empathy”, which could be a downregulation of the affective response in order to diminish “counterproductive” emotions such as fear [ 43 ]. Han and Pappas suggest that rather than surgeons being ‘less empathetic’, they need a degree of suppression in order to minimise the emotional impact of the trauma they inflict as part of their healing to avoid compassion fatigue, burnout, and the consequences of these [ 21 , 44 ]. This links to what participants said about remaining objective and how the concept of empathising ‘too much’ could have negative repercussions.

The fact that this study’s results do not support JSE responses is not necessarily a limitation of the research, as it provides an insight into the complexity of the topic and captures different truths that were not previously recorded in research, namely the distinction between desensitisation and decline in empathy and this being a possible reason for incongruence between results of this study and JSE responses [ 45 ].

Interprofessional relationships also require empathy

While empathy towards patients was not seen as lacking by most participants, empathy towards colleagues was highlighted as an area that could be improved.

Participants felt that competition in their workplace resulted in a negative impact on their training, as they did not feel able to ask for help from colleagues if they needed it for fear of being seen as weak or being gossiped about. When asked why they thought surgical training is so competitive, participants attributed it to being a male-dominated environment or the scope for private practice. This is compelling as these are factors that pertain to the characteristics of people that enter surgical training, rather than, for example, organisational structures and funding issues that result in bottlenecking, and therefore competition, despite there being a shortage of doctors. The answer may be that the characteristics of people in an organisation influence its structure, which in turn influences people’s behaviours [ 46 ].

Participants felt competition had a negative impact on their training. This raises the question of whether competitiveness is conducive to teamwork and collaborative learning. The traditional belief that competition is a prerequisite for surgical training is being challenged.

When discussing ways to improve empathy between colleagues, participants emphasised getting to know colleagues through having consistent teams. They suggested this could also be a way to lighten the competitive atmosphere. Having consistent teams has been suggested in previous research as a way to support junior doctors through trying experiences, such as the COVID-19 pandemic [ 35 ].

The COVID-19 pandemic resulted in an erosion of empathy

Participants highlighted the impact of COVID-19 on their training, shedding light on a new challenge post-pandemic. While some described the empathy erosion they experienced as a result of the volume of death they saw during the pandemic, they also spoke of the lack of respite from work, as many trusts cancelled staff’s annual and study leave. Participants related these issues to feelings of burnout, which is characterised by feelings of “mental exhaustion, depersonalization, and a decreased sense of personal accomplishment” and although fairly common, it should not be underestimated, as burnout is associated with adverse outcomes such as depression, substance abuse, suicide, and attrition [ 47 ]. While burnout was an issue pre-pandemic, its incidence has drastically increased since the pandemic, and this is demonstrated in literature investigating the impact of COVID-19 on frontline workers’ mental health [ 50 , 51 , 52 , 51 ]. These studies focus on the short-term impact of the pandemic, particularly burnout. This study, however, presents novel findings on surgical trainees’ perceptions of the longer-term impacts of COVID upon their training, such as reduced theatre experience, and the ongoing staff shortages due to self-isolation, specific to the UK. Participants’ responses suggest a need for further specific research into the impact this will have on both trainee wellbeing, and training outcomes. Training requirements have not changed in response to the impact of COVID-19, meaning many trainees will have to extend their training in order to meet operating targets. While trainee organisations have published education guidance, they do not necessarily influence policy. Furthermore, as participants mentioned, if senior surgeons do not look at this guidance, they have no awareness of what their trainees need and cannot support their learning [ 52 , 53 ].

Strengths and limitations

The qualitative data this study provided enabled discovery of previously undocumented findings on the nature of empathy change over an individual’s career, which complements quantitative data.

There was some participation bias present in recruitment of participants for the study because those who took part were interested in empathy and self-reflection. Therefore, this could have impacted upon the results whereby the majority of the participants did not perceive a straightforward decline in empathy, but a more nuanced picture.

There may be more variation in perspectives and experiences than we were able to capture in this particular dataset, particularly if this study was repeated in other regions or nations, or with surgeons at later stages of their careers. Therefore, transferability may be a limitation of this study.

Social desirability bias is a “tendency to present reality to align with what is perceived to be socially acceptable” [ 54 ]. The interviews were face-to-face, so as participants could see the researcher’s reactions to what they were saying, they may have been less likely to provide her with answers that could elicit negative judgement [ 55 ].

The limitations of this study highlight areas for possible future studies. A potential study could use anonymised surveys with free-text boxes, but these come with their own limitations, including bias and a scarcity of detailed data [ 56 ]. Alternatively, a mixed-methods project combining JSE responses and interviews could be carried out, but this is not feasible for a student-led project as the JSE is not available freely online; it must be purchased to be accessed [ 57 ]. Although there is much literature validating it, this limits criticism of it since it is not possible to access the official questionnaire without purchasing it.

To conclude, this research provides an insight into surgical trainees’ perceptions around empathy in their practice. Of particular importance is the distinction participants made between a desensitisation and actual decline in empathy, with participants stating they experienced more of the former. The data generated from this study is novel, as surgical trainees are a previously little-researched study population, particularly in the UK. They are important because they provide a detailed insight into surgical training in the UK, and particularly the longer-term impacts of previous structural changes as well as the effects of the COVID-19 pandemic on training.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

core trainee

specialty training

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Acknowledgements

We would like to thank the participants, without whom this research would not have been possible. We would also like to thank Oliver Vlaytchev for his assistance in coding the transcripts.

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Both authors developed the conception of the study and research aims together. P.Y. developed the topic guide and conducted the interviews and transcription, as well as coding and analysis. N.K.G. provided guidance at each stage of research. P.Y. and N.K.G. collaboratively wrote the manuscript. Both authors read and approved the final manuscript.

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Yannamani, P., Gale, N. The ebbs and flows of empathy: a qualitative study of surgical trainees in the UK. BMC Med Educ 24 , 131 (2024). https://doi.org/10.1186/s12909-024-05105-x

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