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Journal club 2: qualitative research

Journal club 2: qualitative research

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Reid, J. (2010)

The second in our series to take the mystery out of critical appraisal looks at articles based on qualitative research

Jennifer Reid’s series aims to help readers access the speech and language therapy literature, assess its credibility and decide how to act upon their findings. The content is based on the critical appraisal education format which has evolved in Fife and is delivered through a series of small group journal clubs. This article explains the difference between quantitative and qualitative research. It explores the value of qualitative research for exploring and creating meaning from participants’ subjective experiences, and for gaining insight into phenomena that are ill-defined or poorly understood. This strength (validity) is also the source of a potential weakness (reliability) as generalisation cannot be assumed. Jennifer presents a 10 question appraisal framework for considering articles which are based on qualitative research. The downloadable version of the framework is available alongside the article.
Reid, J. (2010)

The second in our series to take the mystery out of critical appraisal looks at articles based on qualitative research

Jennifer Reid’s series aims to help readers access the speech and language therapy literature, assess its credibility and decide how to act upon their findings. The content is based on the critical appraisal education format which has evolved in Fife and is delivered through a series of small group journal clubs. This article explains the difference between quantitative and qualitative research. It explores the value of qualitative research for exploring and creating meaning from participants’ subjective experiences, and for gaining insight into phenomena that are ill-defined or poorly understood. This strength (validity) is also the source of a potential weakness (reliability) as generalisation cannot be assumed. Jennifer presents a 10 question appraisal framework for considering articles which are based on qualitative research. The downloadable version of the framework is available alongside the article.

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Published by: Speech & Language Therapy in Practice on May 20, 2013
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SPEECH & LANGUAGE THERAPY IN PRACTICE
WINTER 2010
18
JOURNAL CLUB
 Journal club 2:qualitative research
Jennifer Reid’sseries aims to help you access the speech and language therapy literature,assess its credibility and decide how to act on your ndings. Each instalment takes themystery out of critically appraising a dierent type of journal article. Here, she looks atqualitative research.
 w w w. francar toons.co.u k 
I 
rather like numbers. It seems obviousto me to count things to see if there is apattern, evidence of progress or a usefulcomparison to be made. At this point, you willnot be alone if you are thinking ‘anorak’! Manyof you may feel that as soon as you convertsomething to numbers it loses any kind of real meaning. However, in research design, it’sall about horses for courses; using numbers(quantitative methods) works for studyingsome kinds of phenomena and sticking withwords (qualitative methods) works for others.Here is a story to illustrate the dierent yetpotentially complementary approaches of quantitative and qualitative methods.Amy leads a small team of speechand language therapists working in thecommunity in quite a sparsely populatedarea, so she and her colleagues spend a lot of their time travelling, and timetabling can bequite a juggling act. She notices that referralsare rising quite rapidly in one part of theirpatch while elsewhere they remain prettyconstant. As she may need to change how theservice is deployed to make best use of theteam’s resources, she discusses this with hermanager, and they agree they need to know abit more about what might be going on.What background research would helpthem? Some sources of quantitative datathatmight be available are:1. The local authority publishes regularbulletins on population trends withinage bands in NHS areas, parliamentaryconstituencies, council wards, secondaryschool catchments areas and so on.2. The speech and language therapy servicehas an electronic database of referrals andtheir sources going back over 12 years.3. Most of the team’s referrals come frompractitioners in either primary/communitycare (40 per cent) or education (45 percent).4. Amy’s not sure but feels there may havebeen more inappropriate referrals overthe past year, and she is certain they areseeing a lot more 2-3 year-olds than theyused to.5. Four of the biggest schools they coverhave new headteachers and there havebeen quite a few meetings with them todiscuss roles and responsibilities and togo through the procedures for referral.6. Several health visitors in the area retiredrecently and Amy feels that the team hasnot yet had the opportunity to developstrong working relationships with theirsuccessors. Two community paediatricianposts have also been vacant for more thana year now, and the health board has beenunable either to ll the posts or to securelocum cover. The numerical sources 1 and 2 shouldgive Amy and her manager an indicationof whether the trends in referrals reect (a)changes in the population demographics of the area, or (b) changes in the referral
rate
(theproportion of the population being referred).Items 3 and 4 provide gures forinvestigating whether increasing referralnumbers appear to be associated withparticular sources of referral rather thanacross the board.Items 5 and 6 probably reect some of Amy’s hypotheses about potential sources of temporary uctuation in referral rates. Theycould use their database to check numbersof referrals over time from these schools andhealthcare practitioners to see if the patternof uctuations over time in referral numbersis associated with personnel change.However, knowing
who
is referring more,or fewer, clients than is typical for theirpractitioner group won’t necessarily helpAmy and her manager understand
why 
this ishappening. They need to elicit information onthe perspectives of these referrers.Here is where thequalitative techniquesof document study, observation and interviewcome into their own. In this case, exploringthe content of referral forms (documentstudy) and / or exploring referrers’ decision-making (using individual or group interview
 
SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER
2010
19
JOURNAL CLUB
READ THIS SERIES IF YOU WANT TO
y
BE MORE EVIDENCE-BASED IN YOURPRACTICE 
y
FEEL MOTIVATED TO READ JOURNALARTICLES 
y
INFLUENCE THE DEVELOPMENT OFYOUR SERVICE
Criticial appraisal for speech and language therapists (CASLT)
 Download the ‘qualitative research’ framework document fromwww.speechmag.com/Members/CASLT. Use it yourself or withcolleagues in a journal club, and let us know how you get on (emailavrilnicoll@speechmag.com).
techniques) should help Amy and hermanager understand, and subsequentlymanage, the reasons underlying the changesin their referral numbers.Qualitative methodsare the ‘gold standard’(the method of choice) for exploringand creating meaning from participants’subjective experiences, and for gaininginsight into phenomena that are ill-denedor poorly understood. The strength of thesemethods rests in their ability to reveal theunderlying ‘truth’ of a phenomenon – inresearch terms, its
validity 
. It may be true onlyfor a single individual at one point in time andin one particular context, but listening to orobserving individuals is much more likely toelucidate their subjective experience as theyperceive it than any amount of counting. AsGreenhalgh puts it:“The strength of qualitative research liesin validity (closeness to the truth) – that is,good qualitative research, using a selectionof data collection methods, really shouldtouch the core of what is going on ratherthan just skimming the surface. The validityof qualitative methods is greatly improvedby the use of more than one method incombination (…
triangulation
), by theresearcher thinking carefully about what isgoing on and how their own perspectivemight be inuencing the data (…
reexivity 
),
“ 
(Greenhalgh, 2006, pp.168-9).However, you do need to bear in mind thatthe strength of qualitative methods mayalso be the source of a potential weakness.Generalisation of the ndings of qualitativeresearch to other contexts (people, setting)may not be justied, or at least not withoutappeal to a wider evidence base. It is the
reliability 
of quantitative methods whichgive us condence that the same studywould produce roughly the same ndingsif it were to be repeated elsewhere withdierent participants. This reliability allowsus to generalise with a degree of condencebeyond the immediate context in whicha study has been conducted. Authors of qualitative studies may not help you muchwith this, so you do need to think carefullyabout the context of the research study andhow this may dier from your own. From aservice development point of view there isno point in searching for meaning in studieswhose context or setting will not illuminateyour own service issues. A fantastic researchteam and top-notch methods won’t do youmuch good if you go looking in the wrongplace. As the story goes:Late one evening, a passer-by noticessomeone searching about under a lamppost.“Have you lost something,” says the public-spirited passer-by, “Can I help you?” Thesearcher replies that he has dropped hiscar key and accepts the oer of assistance.Some time elapses while both search theground all round the lamppost. “Are you sureyou dropped it here?” queries the passer-by, “I can’t see it anywhere.” “Eh, no,” says thesearcher, “I dropped it down the road but it’sso dark down there I couldn’t see properly soI came up here where it’s brighter.” There is a plethora of literature on qualitativemethods should you wish to read about thismore widely (Barbour, 2008; Immy, 2010).I also recommend a useful short summaryarticle that is a free download from the BritishMedical Journal (Kuper
et al 
., 2008).
QUALITATIVE RESEARCHFRAMEWORK 
Use the following questions adapted fromGreenhalgh (2006) and CASP (PHRU, 2006) toassess the rigour, credibility and relevance of the study and whether there are implications foryour service. This is set up at www/speechmag.com/Members/CASLT as a document for you todownload, print o and use as an individual orwith colleagues in a journal club.Question 1:Did the paper describe an important clinicalproblem addressed via a clearly formulatedquestion? This may be broken down into whether theaims of the research were clearly stated, whatthe point of the study was, why the problemis important and how the issue is relevant forclinical practice. Studies that use quantitativemethods are expected to have their researchquestion clearly formulated at the outset. Inqualitative designs, however, it is acceptablefor the aims to be inuenced by the dataanalysis (the so-called ‘iterative’ approach, inwhich results inuence questions, which theninuence results, and so on in a cyclic fashion). The authors should therefore explain if and howtheir aims have been shaped during the study.Question 2:Was the choice of qualitative approachappropriate?Was a qualitative method appropriate inthe rst place? Look for evidence that thestudy sought to interpret or illuminate theactions and / or subjective experiences of theresearch participants. Was the research designappropriate to address its aims? Considerwhether the authors discussed selection and justication of their methods.Question 3:How were the participants selected?Have the authors explained how theparticipants were selected? You may be lessfamiliar with qualitative sampling methods– who you select to interview or observe, orwhich texts you choose to analyse – as theyare dierent from the ‘representative sampling’
 
20
JOURNAL CLUB
SPEECH & LANGUAGE THERAPY IN PRACTICE
WINTER 2010
SamanthaPaula(and variations thereof) used in quantitativedesigns. Kuper
et al 
. (2008) have a helpful listof qualitative sampling methods for interviewsor focus groups in healthcare settings. Theseinclude self-evident ones like:
• typical 
or
deviant case sampling
, to lessfamiliar ones like:
• maximum-variation sampling
– samplingfrom a range of perspectives that is wideenough to include all the factors that mightinuence the nature and quality of people’sexperiences, or
• snowball sampling
– each recruit to thestudy generates more participants throughpersonal contact, often used for researchwith ‘hard to reach’ or stigmatised groups.Have the authors explained why theparticipants they selected were the mostappropriate to provide access to the type of knowledge sought by the study? Were thereany discussions around recruitment, such aswhy some people chose not to take part?Question 4:Were the data generated in an appropriate way?Was the setting justied – the
right 
place tolook rather than the
easiest 
?
 
(Not just lookingunder lampposts!) People’s experiencesof your service may be fresh in their mindon the way out of the door from their rstappointment but perhaps they might providemore meaningful information once they haveexperienced some intervention.In my local setting, we recently conducteda series of focus groups with people withaphasia. The participants were all folk whosestroke had occurred relatively recently butwho were now discharged from speech andlanguage therapy. We could be reasonablycondent that:a. the group’s views provided a uniqueperspective on their whole care pathway,which reected our (and other healthcarepractitioners’) current practice,b. the impact of communication dicultieshad been minimised, andc. there was no undue inuence from adesire to maintain current therapeuticrelationships. The ndings are being used as an evidencebase for our current service strategy - forexample, that we invest eort and resourcesin raising awareness of aphasia and healthpromotion for people living with aphasia inour local community.
Qualitativedesignmethodsinvolveexploration andinterpretationvia datageneration
.
 They arestrongeron validity(closeness to thetruth).They are thepreferredmethodsfor poorlyunderstoodor relativelyunexploredphenomena.DocumentsStudy of documents produced by real peoplein real situations (for example, casenotes).PassiveobservationSystematic recording of behaviour and talk innaturally occurring settings.Participant-observationThe researcher takes part in the setting aswell as observing.Semi-structuredinterviewFace-to-face (or telephone) conversationwith the purpose of exploring issues or topicsin detail. Uses a pre-set list of questions ortopics but is not restricted to these.NarrativeinterviewInterview undertaken in a less structuredfashion, with the purpose of getting a longstory from the interviewee (typically a lifestory or the story of how a condition hasunfolded over time). The interviewer usesonly general prompts to “tell me more”.Focus GroupsMethod of group interview which explicitlyincludes and uses the group interactions togenerate data.
Table 1 Qualitative methods
Is it clear how data were generated in thestudy, and have the researchers justied themethods chosen? Table 1 is extracted from therst article in this series to remind you of themost common sorts of qualitative methods.Authors should make their methods veryexplicit so that you can judge whether biasmight have crept in. For example, for aninterview method, is there an indication of how interviews were conducted? If dierentinterviewers were involved, how did theyminimise dierences in personal interviewingstyle? Did they use a topic guide or a standardset of questions and / or prompts?A lot of qualitative research is exploratoryand so researchers are expected to reecton their data as it is being generated. Thismeans that methods may be modied duringthe study. Check whether this happened inthis study, and, if so, do the authors provideenough explanation of how and why?Is the form of data clear? A good test iswhether you can you visualise what thedata looks like (tape recordings, videomaterial, notes)? Illustrations of eld diaries,transcription frameworks and so on are helpful.Now we come to a bit of qualitativetechnospeak. Did they discuss
datasaturation
? This is the point at which yourmethod is generating no new information.Question 5:Was the study conducted within an appropriateethical framework?Participants in a research study need tounderstand what they are letting themselvesin for, why the study is important and howtheir contribution will be used once the studyis completed and disseminated. This is true of all research. However, in qualitative studies theethical issues can be trickier, since the personalexperiences of the participants will notnecessarily be reduced to a set of anonymousnumbers. There are potential consequenceswhen people’s personal experiences areexposed both to themselves and to others.Have the authors discussed the ethical issuesraised by the study, such as informed consent(and how they achieved this where children orparticipants with communication dicultiesare concerned), condentiality and how theyhave handled the eects of the study on theparticipants during and after the study?It’s not enough just to know that approvalwas gained from a recognised ethics committee(but they should mention this as well).Question 6:What perspective is the researcher coming from,and how has this been built into the study?Another bit of 
qualitative techno-
speak is
refexivity 
the extent to which
the researchers
critically examined
their own role,
potential bias and
inuence duringthe course of the
study. You need to
look at reexivityin the formulation of 
the research questions, in the data generation,including how they recruited their sample and
in their choice of location. It is also criticalthat they explain how they responded toevents during the study and considered theimplications of any changes in the researchdesign.

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