Qualitative health research in practice

York UniversityHaving spent many years editing ‘Speech & Language Therapy in Practice’ magazine, it’s not surprising that an event titled ‘Qualitative health research in practice’ had huge appeal. In placing the focus on exploring the many processes of doing qualitative research, organisers Cath Exley, Nina Hallowell and Tim Rapley created a friendly and stimulating space that enabled PhD students and early career researchers to bring uncertainties, challenges and realities into the open.

The real mark of a worthwhile event is not so much what it does on the day but how it continues to percolate. This will work in different ways for different participants. For this reason, my blogpost doesn’t offer a speaker-by-speaker account. Instead, I hope to show how the event is already helping me reflect on aspects of qualitative research practice that really matter.

1. How we frame ‘the problem’ really matters

Our framing of the problem for investigation informs our research choices, and thus builds assumptions into all aspects of study design. These assumptions affect everything from who we recruit and who we do not, to the data we generate, to how we choose to share our findings. Framing is a political act: it accepts or challenges the status quo, it is done and used for different purposes, and it can enable or prevent us hearing what may be central to a problem.

Framing ‘the problem’ can involve critiquing dominant assumptions, but challenging our own assumptions and recognising where, how and why they may be coming into play is integral to all good qualitative research. As clinician researcher David Hamilton said, we are filters of – not windows on – data, and we need to be honest about our sieve.

Exemplifying this kind of honesty, Siân Benyon-Jones explained how she made assumptions about procedures she would have to put in place to get her study through an NHS Research Ethics Committee. She got ethics approval but, because she hadn’t designed her research around the needs of the study, recruitment didn’t work until she problematised those assumptions and changed her approach.

2. Recognising that something else might exist really matters

All research is partial. Jo Wildman’s paper made me wonder how we can remain open to the possibility that we are missing something significant because of our study design. Jo is doing mixed methods work with the Newcastle Thousand Families Study cohort, which has been providing longitudinal data since 1947. She explained that how we see ‘healthy’ or ‘successful’ ageing has largely been limited by quantitative methods with a biomedical slant. While they provide an important chronicle of trends, associations and timings, they can’t recognise variation in what is meaningful. However, Jo’s in-depth qualitative interviews have captured narratives of successful ageing as ‘going and doing’, along with the previously unrecognised importance of social ties and relationships. This new knowledge has enabled the research team to adapt quantitative data collection accordingly.

The choices we make about the setting of our research also influence what we might be missing. As Diane Trusson has found, being outside a medical setting may mean participants construct their stories differently, so they are much more contextualised as part of their life. Rupal Patel also took her research into the community so it would be more inductive, and one consequence is that her data is full of complexity and contradictions. Rupal therefore drew our attention to one of the dilemmas facing qualitative researchers who have a remit to inform practice or policy: to what extent do we work against this complexity to find ‘an answer’, versus working with it to present the diversity of what exists?

3. Relationship work really matters

Qualitative research is about people in their social contexts. People are active agents, not passive blank slates. Roles are not fixed, and people and relationships are always changing. As Jenni Remnant reflected, this means that any kind of collaboration introduces politics and dynamics that you may not be able to prepare for beyond making and fostering relationships, being nice and honest, and offering cake.

A running theme was how relationship work with ‘gatekeepers’ and potential participants is crucial for study recruitment. This is not necessarily comfortable; it can involve “hanging out” at a clinic (Siân) or “lingering around” a temple (Rupal). As Siân says, recruitment needs onsite, in person work, and an information pack can’t do it.

Once a study is underway, relationship work might involve communicating critical data back to your colleagues in a way that represents the difficulties they face (David). It might also mean you compromising your own preferences to accommodate those of your participants, as Siân found when she discovered many preferred a telephone interview over face-to-face.

4. It really matters that concepts are rounded (and not hollowed) out

Qualitative research is full of concepts that have been proposed as holistic and are therefore unlikely to be definable in one way. Ashok Patnaik, for example, finds ‘culture’ has become “a vast, global, aggregative concept” that is applied in a “wildly” divergent way. He argued that it has become so “hollowed out” and conflated with other concepts that it is of no practical use. Ashok proposed dealing with such “quicksand” concepts by having narrower and tighter definitions with operational consistency, clear boundaries and uniqueness. I think this is one possible strategy, but I can’t go along with it as a rule of thumb for qualitative research – one of the strengths of language is its fluidity, and the way you choose to handle a concept and its boundaries depends on why you are using it in the first place and what you want it to be able to do.

On the other hand ‘rounding out’ concepts (Tim Rapley) is undoubtedly qualitative work. The emotional work of research was raised one way or another by all speakers. Tim observed that there is a tendency to use the concept as “a gloss” and we need to take it more seriously by rounding out what these emotions are.

Clinician researcher David Hamilton suggested a way to tackle this:
a) Describe one concept in baby steps
b) Show your working and explain your theory
c) This will expose big, gaping holes
d) These holes will lead you to ask ‘why?’ which directs your next steps.

In some qualitative research, ‘rounding out’ concepts is key to ‘theoretical saturation’. Questions were raised about the possibility of theoretical saturation, which may partly be a consequence of common misunderstandings, but may also reflect a deeper unease. This has been addressed from a realist perspective in a recent blog by Nick Emmel.

5. Transparency about process really matters

Being open about the what, why and how of our processes is essential to developing as applied qualitative health researchers with sociological imagination. As a clinician researcher, David Hamilton wants to play a bridging role, but is aware of the danger of ending up with the worst of both worlds. The work of sociologist Erving Goffman has clearly helped David notice the ethical and practical tensions of his dual role and how these play out in the front stage, backstage and subplots of his settings. Once we become aware of what might be going on, we can’t pretend it doesn’t exist.

Valuing and being transparent about process therefore takes courage, but may leave us better equipped to embrace the accidental (Diane), live with uncertainty and change (Jenni) or enter the unknown (Becca Patterson). Becca is in the first year of her PhD. Her presentation reminded me how much preparatory work is needed before you even know if you will get funded, and of the importance of creating your own support network early on.

Now in my second year, this conference was my first go at presenting an aspect of my PhD to an external audience. I spoke about why and how I have used a realist sampling strategy in the early stages of an intended meta-ethnography. This prompted discussion about there being no one ‘correct’ way of synthesising primary qualitative research reports, hence the research community should stop looking for one and concentrate instead on describing what we do and why. Preparing a presentation, delivering it, being questioned on it and getting informal feedback is nerve-racking. However, it is also a fantastic way of understanding what you are doing, who might be interested in it, and how it might make a contribution.

The British Sociological Association MedSoc Applied Qualitative Health Research Group event (#AQHR) was on 13th May 2015 at York University. Speakers were: Siân Benyon-Jones, University of York; Diane Trusson, University of Nottingham; Rupal Patel, University of Nottingham; Jenni Remnant, Newcastle University; Avril Nicoll, University of Stirling; Ashok Patnaik, University of Huddersfield; Jo Wildman, Newcastle University; Becca Patterson, Newcastle University; David Hamilton, Newcastle University.

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