Tell me a story : Qualitative Research in Health Sciences Education

This week, I invited Libby Alexander, Research Assistant in the Office of Health Sciences Education to talk about what she and Dr. Leslie Flynn have been working on to provide our faculty with new learning about qualitative research.  Here’s what Libby wrote to us:

I am not a health professional but probing people is a key part of what I do.

In interviews, I mean.

That is to say, as a research assistant in health sciences education, my main task is to elicit different kinds of information from learners in order to inform the practice of teaching, learning and scholarship. Some of this information is in numerical form, measuring knowledge, attitudes and beliefs. I invade your inboxes with countless invitations to electronic surveys. These are followed by cheerful “reminders” that my carefully crafted survey has yet to be graced by your keystrokes. Translation: Please enhance my sample size! Ten minutes, I promise.

Yes, I’m that girl.

But sometimes, the numbers game is neither sufficient nor appropriate for the question under investigation. We are textual creatures after all, as illustrated in loving gazes bestowed upon phones everywhere. It can also be demonstrated in the clinical encounter. When I come in for an appointment, while inquiring about my symptoms, a physician must quickly make sense of my “patient text” which is all over the place, trying to re-assemble my descriptions into a coherent narrative with the objective of identifying the underlying patterns. When I say “But let me explain, doc”, I’m not simply listing my ailments but trying to contextualize them so that you understand what I’m experiencing.

In educational research, we can use this approach to examine the “lived experience” of learners and teachers as they go about the business of developing expertise in health care. Qualitative inquiry enables us, not only to explore the impact of educational strategies, but also unpack the processes that promote or inhibit learning. Going beyond “Does it work?” to “How does it work?”.

Expertise is a process of development, an unfolding story that integrates skill acquisition and identity formation within the bigger picture of becoming a health professional. From the standpoints of learners and teachers, we can gain a picture of the learning environment and identify the complex aspects that shape the “outcomes” that anchor our work.

For example, Kennedy, Lingard, Baker, Kitchen and Regehr (2007) were interested in the relationship between clinical supervision of medical trainees, patient safety and the quality of patient care. A traditional, outcomes-based study might ask “Does increased supervision of trainees improve quality of patient care?”

But look at the big concepts embedded in this question: “supervision of trainees” and “quality of patient care”. Kennedy et al state that the concept of supervision is multifaceted and poorly operationalized making it difficult to picture what an increase would look like.  So what they chose to do, through observation and interviewing of several teaching teams, was to create a model of “patterns of supervision” that occurred in clinical teaching programs.

This represents a Grounded Theory approach used to develop an explanatory framework of clinical supervision. In their analysis, different levels of supervision emerged: routine oversight, responsive oversight and direct patient care.

In this example, the “results” did not point to outcomes but rather unpacked the complex nature of clinical supervision to provide concrete components for programs to target through policy, faculty development and further research.

The Qualitative Research Series from the Office of Health Sciences Education and Office of Faculty Development

Interviews, focus groups, observation and document analysis constitute some of the qualitative approaches used in education research. These methods can sometimes be met with skepticism or accusations, even, of subjectivity, lack of rigour and general wishy-washyness. These concerns and assumptions may inhibit educational researchers from seeing a broader range of scholarly possibilities in their work.

This is why under the guidance of Dr. Leslie Flynn, the Office of Health Sciences Education worked in conjunction with the Office of Faculty Development to offer a series of workshops entitled “Qualitative Research Series: Approaches for Healthcare Leaders”, designed to provide a general overview of qualitative methodology. In doing so, we hoped to de-mystify the murkiness to reveal what is, in fact, a systematic, yet non-linear approach.

We started in October of 2013 with an introductory session by Drs. Richard Reeve and Christopher DeLuca from the Faculty of Education. Next, Dr. Flynn and I put on 2 workshops covering the development of research questions, data collection and analysis. The final one in April will feature Dr. Lorelei Lingard discussing writing for publication.

So what did we talk about? In a blog, it is difficult to summarize the intense processes of qualitative research simulated in our workshops. Instead I will briefly describe some key points.

1.     Qualitative inquiry is a different way of seeing your area of interest

This type of methodology allows us to make implicit phenomena visible.

Some of the types of things in education that we can look at include processes, meanings, structures, perspectives, cultures and relationships. These new ways of seeing enable us to ask different questions.]

In the workshops we introduced 5 main approaches in qualitative research, briefly described in the table below.

Narrative Describing the development of an experience by telling a story
Phenomenology Capturing an essence or core features of an experience
Grounded Theory Generating an explanation based on people’s described experiences
Ethnography Describing shared cultural meanings
Case Study Illustrating an issue through bounded cases

Cresswell (2007) provides a comprehensive overview of these approaches. He recommends using them to “foreshadow” your research question as they specify what kinds of data to collect. In using the example from Kennedy et al above, they asked “What does clinical supervision look like?”  More specifically, they looked at in-patient teaching wards of two academic health sciences centres. Grounded theory starts from what is observed to build explanatory frameworks. Their data collection was shaped to generate a rich, detailed picture of the types and conditions of supervision that occurred in teaching teams. This allows further research to look at more specific relationships between supervision and patient care.

2.     The importance of developing a solid research question to anchor your project

Based on the literature and our own experiences in research and consultation, we developed a framework to help participants in focusing down an area of interest into a workable research question. We got them to consider the purpose of their inquiry and breaking down their topic into key components. In small groups, participants discussed their ideas with each other as they navigated the process. We then moved on to linking the research question to data collection by learning to create an interview guide.

In actual practice, this is a long, intense, iterative process. From our experiences in both practicing and consulting with others about research, we have seen the struggles in moving things forward, if you don’t have a sufficiently focused, well-articulated research question. Think of the research question as a roadmap for the journey of your inquiry. It drives the steps for data collection, analysis and presentation. A lack of clarity and focus can lead you astray.

3.     Interpreting data and building meaning:  Identifying, Organizing and Connecting

When lived experience becomes tall stacks of paper, it’s easy to become overwhelmed: “Isn’t this all just subjective? How is this evidence of anything?” In qualitative research, “themes” aren’t just common sense bullet points gleaned exclusively through intuition. They are the product of systematic identification, filtering, comparison and classification. But at the same time, we must be vigilant not to sever this abstraction from the lived realities of our participants—so there is a place for intuition.

We guided workshop participants through some core procedures in analysis as briefly described below.

 

Immersion Reading and summarizing
Identifying units of Meaning Coding
Organizing codes to make sense of the data Defining categories and concepts
Building connections between ideas Developing themes to answer your research question

While workshops are a linear format, qualitative research is an iterative spiral where you are constantly moving between literature, theory, interpretation and methods—all with the research question in view.  In developing your concepts and themes, you are trying to arrive at the “best fit” for your data based on systematic comparison, classification and revision.

The process yielded some rich conversation with the group who asked a lot of great questions. Interpretation is a social process, so we incorporated a lot of group work in our workshops.  In breaking down the process into key components, we hoped to demystify analysis and spark new ways of thinking about educational topics. The room was abuzz with energy as faculty, educational specialists and research associates engaged with the possibilities of a different paradigm to shape their scholarly work.

Community of Practice

This was our first run at the workshops and we definitely learned a lot. Taking a complex, intense, constantly evolving process and translating it into a set of introductory workshops was certainly challenging. But building in opportunities for dialogue among participants and with the facilitators revealed an amazing potential for building community. The experience drove home that creating such spaces are essential for fostering the scholarly imagination in teaching and learning.

Creswell, J. (2007). Qualitative Inquiry & Research Design: Choosing among five approaches (2nd Ed.). Sage: CA.

Kennedy, T., Lingard, L., Baker, G., Kitchen., L & Regehr, G. (2007). Clinical oversight: Conceptualizing the relationship between supervision and safety. Journal of General Internal Medicine, 22(8), 1080-1085.

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