Qualitative Research: A Different Way of Understanding

How do we determine our patients' needs and effective ways to meet those needs?

This question is both philosophical and practical. Clinicians make decisions and recommendations every day based on their understanding of the right way (or at least a right way) to address specific challenges. What is the basis for that knowledge, and what gives us the confidence to act on it when designing an intervention or a treatment plan? In addition to relying on our own clinical experiences, we are encouraged to refer to the results of systematic investigations—research—to analyze the relevant facts about a case and reach appropriate conclusions. Researchers adopt different approaches to obtain knowledge, and it can be challenging for clinicians with limited education in or exposure to research methods to determine which type is most effective in addressing different clinical questions. In Summer 2019 the editors of Prosthetics and Orthotics International (POI) published an editorial addressing the limited number of qualitative research articles that have been published in the journal. The editors point out that many of their readers are familiar with "personal stories about the experience of living with a disabling health condition" and they "see a unique opportunity to illuminate these experiences through rigorous qualitative research...." 1 They go on to give a succinct description of qualitative research and state that "qualitative research methods provide a way to describe and characterize the experience and perceptions of participants in a systematic way that engenders trustworthiness in the findings, and provides high-quality evidence that can inform clinical practice or future research." 1

Clinicians may be unaware of how qualitative research differs from quantitative research and the type of knowledge that can be gained from the qualitative process. This article describes key features of qualitative research to introduce how those methods can provide different types of meaningful answers to clinical questions.

Paradigms for Obtaining Knowledge

Understanding differences between research methods requires an understanding of the belief systems that form the foundation for each. Advances in science that began several hundreds of years ago supported the idea that "one can be certain…of knowledge that is verifiable through measurement and observation." 2 This idea forms the basis for a quantitative approach to knowledge acquisition. Through the implementation of rigorous methods that control variables, including the involvement of the investigator, and careful measurement, a researcher can determine the objective reality of a phenomenon being studied. Cause and effect can be determined, and the results can be generalized to other similar cases. In the quantitative approach, "inquiry is seen as the objective discovery of truth, and the investigator the impartial discoverer of these truths." 2 Quantitative research methods can address many of the situations clinicians face, including "when ‘factual' data are required to answer the research question; when general or probability information is sought on opinions, attitudes, views, beliefs, or preferences; when variables can be isolated and defined; when variables can be linked to form hypotheses before data collection; and when the question or problem is known, clear, and unambiguous." 3 When these methods are applied to clinician questions, the results can be used to assess outcomes of treatment, and over time can be used in predicting how specific interventions will improve patient safety and function.

However, there are limitations to viewing the world as a collection of objective data that can be understood through sufficiently rigorous quantitative methods. Many of the questions clinicians have cannot be answered using those methods, including some that are most important to the everyday experiences of patients. As the sociologist William Bruce Cameron pointed out, "Not everything that counts can be counted, and not everything that can be counted counts." 4 According to Hammarberg et al., "‘qualitative' methods are used to answer questions about experience, meaning, and perspective, most often from the standpoint of the participant. These data are usually not amenable to counting or measuring." 3 From the qualitative research perspective, the world consists of "multiple constructed realities" rather than one objective reality. "‘Multiple' means that there are always several versions of reality; ‘constructed' means that participants attach meaning to events that occur within their lives, and that this meaning is an inseparable component of the events themselves." 2

Quantitative research can reveal important information about the function of prosthetic components and the patients using those components, but it gives little insight into why patients prefer one component over another, what factors influence their pattern of use, or how that intervention adds or detracts from their life experience.

The philosophical foundations of the qualitative paradigm may sound strange to many of us who automatically think of the quantitative paradigm when we think about science. A clinical example may help to demonstrate the practical implications of a qualitative approach. Clinicians have limited options for assessing whether a prosthetic socket fits appropriately. Since there is no objective method for measuring appropriateness, we make determinations based on some combination involving observations of the patient's skin and the patient's reports. While the effect of some socket fit problems can be easily observed as discoloration, abrasions, or other features of the residual limb, discomfort is a phenomenon that each patient experiences uniquely. One patient may report that a specific amount of pressure is comfortable, while another reports that the same pressure is uncomfortable. Additionally, patients' experience of discomfort or pain may be influenced by many other factors besides the physical contours and construction of the socket, including their personality and temperament, the extent of their social support, and their expectations of the roles they fill in everyday life. Multiple realities of socket fit are constructed based on different patients' experiences of wearing their particular sockets and the meaning they attach to a variety of factors that influence that experience. While quantitative methods can determine some important aspects of socket fit, the most important questions may be answered in a more useful way using qualitative methods.

Qualitative Methods

Qualitative research methods provide a way to investigate different types of questions and help us understand the meaning patients attach to their experiences. Table 1 identifies common designs that can be implemented depending on the question being examined and the goal of the research. Ethnography involves researchers immersing themselves in the "participants' environment to understand goals, cultures, challenges, motivations, and themes that emerge." 5 Phenomenology has the goal of "understanding the meaning participants place on whatever is being examined." 5 Grounded theory is focused on providing "an explanation or theory behind the events." 5

Each of these methods involves "the systematic collection, organization, and interpretation of textual material derived from talk or observation." 6 The POI editors describe the process of data acquisition and analysis this way: "Data are often obtained during one-on-one interviews or small group discussions, where details of the participants' experiences can be explored and recorded. Audio recordings are usually transcribed and analysed line-by-line to characterise each participant's experience." 1 This time-consuming process is one of the disadvantages of these research methods.

A quantitative approach attempts to minimize the extent to which the researcher influences the research process. When conducting qualitative research, however, the investigator does not attempt to maintain objectivity and instead, becomes an active part of the research process. "In qualitative research the objective stance is obsolete, the researcher is the instrument, and ‘subjects' become ‘participants' who may contribute to data interpretation and analysis…." 3 For example, an interviewer may frame questions and respond to the participants in ways that highlight certain aspects of their experience to direct the interview toward topics that address the research question most effectively.

Interpreting Qualitative Research

Qualitative research has been criticized as being less rigorous and objective than quantitative research, involving smaller sample sizes that may not represent the larger population, and being "biased by the researchers' own experiences or opinions." 3 Keeping these perceived weaknesses in mind, there are ways for clinicians to assess the quality of qualitative research studies. Qualitative research is considered credible when the results "are recognizable to people who share the experiences and those who care for or treat them." 3 This is analogous to internal validity in quantitative studies. Clinicians can assess the extent to which the results of the published report match their own observations and the experiences of their patients. In quantitative research, external validity refers to the extent to which the results of a study can be generalized to other individuals at other places and times. While the primary goal of qualitative research is to investigate each participant's perspectives within a specific context, and is therefore not as easily generalized to a broader population, qualitative results can be evaluated for applicability or transferability to other individuals and contexts.

In qualitative research, a larger group of participants and more data do not necessarily result in more meaningful (and transferable) results. Saturation occurs when "data tend towards repetition or where data cease to offer new directions or raise new questions." 3 For example, a researcher asking a group of individuals with transhumeral amputations to describe why they choose to use or not use a prosthesis may begin to hear certain reasons repeated, and be able to identify common themes in the responses. At some point, asking more participants about their experiences would not be likely to reveal more reasons for use or abandonment. The credibility of the study depends on how closely the themes identified by the researcher match what clinicians observe in clinical practice. Results are considered consistent or reliable when "given the same data other researchers would find similar patterns." 3 Anyone reviewing qualitative research reports, which often include direct quotations from participants to represent the themes identified by the researchers, could compare those results to their experience with patients in similar situations.

Despite important methodological differences, qualitative research reports "should contain the same robust procedural description as any other study. The purpose of the research, how it was conducted, procedural decisions, and details of data generation and management should be transparent and explicit. A reviewer should be able to follow the progression of events and decisions and understand their logic because there is adequate description, explanation and justification of the methodology and methods." 3

Conclusion Much of the knowledge we need about our patients is best derived from qualitative methods that match more closely the types of interactions we have in clinical practice. Asking questions to understand our patients' experiences and the meaning they attach to them forms the foundation of clinical practice and qualitative research. The insight we gain from this process may be more meaningful to our clinical decision-making than counting things that can be counted. "Understanding…, which is a hallmark of qualitative research, …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." 7 Hammarberg states it this way: "We need the different kinds of evidence that is generated by qualitative methods. The experience of health, illness, and medical intervention cannot always be counted and measured; researchers need to understand what they mean to individuals and groups." 3

An article in Nature addresses the negative view that many quantitative (hard science) researchers have of qualitative (soft science) methods: "‘Hard' scientists need to get over their disdain for their ‘soft' colleagues. The study of society can't just be left to poets and politicians. As the almost boundless complexity of physical and biological systems becomes increasingly apparent, along with the pressing need to better understand patterns of human behaviour, now is as good at time as any for a rapprochement between the two wings of the scientific academy." 8 Many researchers in our profession have been conducting high-quality qualitative and mixed methods studies. The editors of POI have implemented several changes to the author guidelines to encourage the submission of qualitative articles for review, so we can anticipate having access to even more information of this type. Clinicians who use those reports to inform clinical decisions will likely find that their practice more effectively addresses our patients' priorities.

John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education. References 1. Dillon, M. P., S. Fatone, N. Ramstrand, and B. J. Hafner. 2019. Prosthetics and Orthotics International welcomes qualitative research submissions. Prosthetics and Orthotics International 43(4):366-68.

2. Carter, R. E., J. Lubinsky, and E. Domholdt. 2011. Rehabilitation research: principles and applications. St. Louis, MO: Elsevier Saunders; 2011.

3. Hammarberg, K., M. Kirkman, and S. de Lacey. 2016. Qualitative research methods: When to use them and how to judge them. Human Reproduction 31(3):498-501.

4. https://quoteinvestigator.com/2010/05/26/everything-counts-einstein . Accessed 2.23.20.

5. https://measuringu.com/qual-methods . Accessed 2.23.20.

6. Malterud, K. 2001. Qualitative research: Standards, challenges, and guidelines. The Lancet 358(9280):483-8.

7. Aspers, P., and U. Corte. 2019. What is qualitative in qualitative research. Qualitative Sociology 42(2):139-60.

8. In praise of soft science. 2005. Nature 435(1003). https://doi.org/10.1038/4351003a .

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