Over 60 researchers had gathered to explore the question, ‘What can we do with applied qualitative health research?’ There was no shortage of answers.
1. We can do more with qualitative research to improve trials
Helen Eborall of the SAPPHIRE group called for more attention to qualitative development work on interventions before they are piloted. For a current trial, Helen’s team adapted a framework for ‘mhealth’, the name given to interventions supported by mobile devices. Phase 1 (conceptualisation) involved observation of ‘what happens on the ground’ combined with a focused literature review to inform the intervention objectives. Phase 2 (formative research) was carried out with focus groups comprising people involved in a previous trial. The phase 3 focus groups pre-tested the intervention in real-time to see how it might work or not. This meant that, rather than the final phase 4 revealing major problems with the intervention and its implementation, it was a genuine pilot used only for tweaking.
Helen emphasised that this process “really changed the eventual intervention”. For example, it demonstrated that, in order to work, the intervention had to be tailored according to a participant’s previous experience, motivation and confidence. This was then built into the design.
Process evaluations alongside randomised controlled trials are now common, but Laura Sheard and Claire Marsh showed why they are so important in ‘making sense’ of statistical data. The PRASE trial is investigating how action planning informed by patient feedback is used by nursing teams to improve patient safety on hospital wards. The process evaluation methods include observation and analysis of action planning meetings. This means explanatory non-verbal communication can be captured as well as what is said. Follow-up structured telephone interviews with lead nurses establish if intentions were implemented and what contextual information might be relevant. Fieldworker diaries add another dimension in terms of ward culture.
The process evaluation is highlighting many reasons why change is difficult, even with action planning, and why some changes are more likely to be implemented than others. Changing a culture is particularly difficult, and most nursing teams don’t feel they can challenge the status quo.
2. We can do more with qualitative research to drive improvement
One method which can leave “a legacy of cultural change” is experience-based co-design (developed by Paul Bate and Glenn Robert). However, as this participatory action research approach involves a process of discovery interviews and observation leading to the production of ‘trigger films’ for discussion, it is costly and time intensive. As an alternative, Louise Locock tested the use of national films from an archive. Patients and staff watched the films at a co-design workshop, and used their response to them to plan improvements together. As well as removing the bulk of the cost and development time, the national films were acceptable to both patients and staff. They may have reduced some of the social awkwardness that can arise around a personal story, and allowed each party to see the other as fallible, caring human beings.
Louise notes that, while the improvements that predominate are seemingly small, they can be “momentous” for those involved, for example the implications for communication, eating and overall dignity when a patient’s teeth travel with them to another ward. Louise suggests that, rather than leaving them feeling criticised, the process “reconnects healthcare professionals with the values they joined the NHS for in the first place”.
Experience-based co-design draws on narrative persuasion and transportation theory. Also making the case for the use of theory in qualitative research was Andrew Morden (MOSAICS). Andrew is interested in “getting inside practice dynamics”, and is investigating how resources and training can be developed, implemented and sustained in a way that works for patients and practitioners. He says Normalisation Process Theory, which I wrote about in a previous post, has helped explain and guide the research.
3. We can structure qualitative methods for different purposes
Ann Hutchinson also wanted to bring patients and practitioners together to understand how community management of people with long-term conditions could be improved. To do this, she used linked interviews. This means a patient (with or without a family member) is interviewed first. With their agreement, the researcher then interviews a healthcare professional who provides care to that patient.
Ann emphasised the linkage is not for ‘triangulation’ of findings, but to exploit the interaction of different perspectives to help explain and address a problem. Linked interviews take advantage of the particularisation of qualitative methods, and Ann found that emphasis on a specific patient seemed to enthuse the healthcare professionals.
When research concerns a social behaviour that is highly socially determined, qualitative methods are especially useful, and Jenny Dalrymple also wanted to focus on the particular, in this case how people’s ‘scripts’ about sexual health had changed over time. As I am planning to use episodic interviews in my PhD, I was reassured to hear from Jenny how they had worked in practice to take people back to how they felt and behaved at specific times in the past.
Depending on how they are convened, focus groups can be more like qualitative interviews, or more like participant observation. In either case, Sally Brown pointed out that interaction is the critically useful element of focus groups that often gets missed. She has found colour coding of participants’ contributions in the transcript gives a useful visual impression of power dynamics and comfort with communication in the group.
Sally has chosen to run focus groups in naturally occurring settings. This means that, rather than convening groups somewhat artificially in a neutral environment, the research is taken to places where families, friends or colleagues happen to be hanging out together. As a consequence, what is said and done, and the way it is said and done, may offer a more realistic picture and be more acceptable to participants. This is especially important to consider when our questions are around ‘social’ learning or decisions.
4. We need to value and support the work of qualitative research
The social learning aspect of the day was particularly obvious during discussions around ethics, self-care and reflexivity.
Sarah Chew and Pam Carter asked to what extent we are colluding in a deception, wasting resources and compromising ethical principles by agreeing to undertake Good Clinical Practice training. Although this is commonly required for any health service research, it was specifically developed as a safeguard for patients in trials of medicinal products and offers no protection to researchers or participants in ‘messier’ social projects.
Judy Richards also emphasised the need to move beyond the processes of qualitative research and recognise the decisions and responsibilities borne by researchers carrying out such emotionally exhausting work. Her presentation about recognising our vulnerability, reducing our isolation and finding supportive strategies provoked a lot of discussion when we divided into groups. I was reminded of two resources that have proved helpful to me. The first is a book aimed at caring professionals, ‘The Resilient Practitioner‘. The other relates to the difficulty of exiting interviews when people have been in distress, Deborah Hersh’s work on the emotional labour of discharging clients.
5. We can use qualitative research to go beyond the specific
On a day of sharing the practice and experience of qualitative research, it was appropriate that keynote speaker Carl May should urge us to participate in the “intellectual conviviality and collegiality” of communities of practice.
Moreover, as we looked to the future of qualitative research, it was also fitting that he should reflect on how we have arrived at this point. Returning to Newcastle University where he did much of the development work of Normalisation Process Theory, Carl took the opportunity to theorise his own research journey in different ways: the types of research questions he has asked, the relationships he has examined and the conceptual problems he has addressed. Although we now take interdisciplinarity for granted, Carl pointed out it was not always this way. That development may explain why methods have come to dominate our conversations, as they offer a shared vocabulary focused on a problem. We are also now “living in a golden age of middle-range theory” and need to take advantage of all that has to offer.
Through health research, we aim to identify, characterise and explain things that can be empirically demonstrated to matter. What looks like a small and isolated qualitative study is not when we move it beyond the specific. Using theory as a window, we can link empirical research with practice tools and policy objectives. Qualitative health research therefore offers “opportunities for reshaping and reinvigorating” the way that healthcare professionals, researchers and patients understand their world, and we should be ambitious in taking it forward.
Thank you to my funder ESRC for enabling me to attend this symposium, to the organisers including Cath Exley and Tim Rapley, and to all the speakers and participants for making it such a useful and friendly event.