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Abstract
Background: Qualitative methodologies are increasingly popular in medical research. Grounded theory is the
methodology most-often cited by authors of qualitative studies in medicine, but it has been suggested that many
‘grounded theory’ studies are not concordant with the methodology. In this paper we provide a worked example
of a grounded theory project. Our aim is to provide a model for practice, to connect medical researchers with a
useful methodology, and to increase the quality of ‘grounded theory’ research published in the medical literature.
Methods: We documented a worked example of using grounded theory methodology in practice.
Results: We describe our sampling, data collection, data analysis and interpretation. We explain how these steps
were consistent with grounded theory methodology, and show how they related to one another. Grounded
theory methodology assisted us to develop a detailed model of the process of adapting preventive protocols into
dental practice, and to analyse variation in this process in different dental practices.
Conclusions: By employing grounded theory methodology rigorously, medical researchers can better design and
justify their methods, and produce high-quality findings that will be more useful to patients, professionals and the
research community.
Keywords: qualitative research, grounded theory, methodology, methods, dental care
© 2011 Sbaraini et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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now diverse and somewhat fractured, existing in four (application of fluoride varnish, supervised monitoring
main types, with a fifth emerging. Types one and two of dental plaque control and clinical outcomes)[38].
are the work of the original authors: Barney Glaser’s As the RCT unfolded, it was discovered that practices
‘Classic Grounded Theory’ [13] and Anselm Strauss and in the intervention arm were not implementing the pre-
Juliet Corbin’s ‘Basics of Qualitative Research’ [14]. ventive protocols uniformly. Why had the outcomes of
Types three and four are Kathy Charmaz’s ‘Constructi- these systematically implemented protocols been so dif-
vist Grounded Theory’ [15] and Adele Clarke’s postmo- ferent? This question was the starting point for our
dern Situational Analysis [16]: Charmaz and Clarke grounded theory study. We aimed to understand how
were both students of Anselm Strauss. The fifth, emer- the protocols had been implemented, including the con-
ging variant is ‘Dimensional Analysis’ [17] which is ditions and consequences of variation in the process.
being developed from the work of Leonard Schaztman, We hoped that such understanding would help us to see
who was a colleague of Strauss and Glaser in the 1960s how the norms of Australian private dental practice as
and 1970s. regards to tooth decay could be moved away from dril-
There has been some discussion in the literature ling and filling and towards evidence-based preventive
about what characteristics a grounded theory study care.
must have to be legitimately referred to as ‘grounded Designing this grounded theory study
theory’ [18]. The fundamental components of a Figure 1 illustrates the steps taken during the project
grounded theory study are set out in Table 1. These that will be described below from points A to F.
components may appear in different combinations in
other qualitative studies; a grounded theory study A. An open beginning and research questions
should have all of these. As noted, there are few exam- Grounded theory studies are generally focused on social
ples of ‘how to do’ grounded theory in the literature processes or actions: they ask about what happens and
[18,19]. Those that do exist have focused on Strauss and how people interact. This shows the influence of sym-
Corbin’s methods [20-25]. An exception is Charmaz’s bolic interactionism, a social psychological approach
own description of her study of chronic illness [26]; we focused on the meaning of human actions [39].
applied this same variant in our study. In the remainder Grounded theory studies begin with open questions, and
of this paper, we will show how each of the characteris- researchers presume that they may know little about the
tics of grounded theory methodology worked in our meanings that drive the actions of their participants.
study of dental practices. Accordingly, we sought to learn from participants how
the MPP process worked and how they made sense of
Study background it. We wanted to answer a practical social problem: how
We used grounded theory methodology to investigate do dentists persist in drilling and filling early stages of
social processes in private dental practices in New tooth decay, when they could be applying preventive
South Wales (NSW), Australia. This grounded theory care?
study builds on a previous Australian Randomized Con- We asked research questions that were open, and
trolled Trial (RCT) called the Monitor Dental Practice focused on social processes. Our initial research ques-
Program (MPP) [27]. We know that preventive techni- tions were:
ques can arrest early tooth decay and thus reduce the
need for fillings [28-32]. Unfortunately, most dentists • What was the process of implementing (or not-
worldwide who encounter early tooth decay continue to implementing) the protocols (from the perspective
drill it out and fill the tooth [33-37]. The MPP tested of dentists, practice staff, and patients)?
whether dentists could increase their use of preventive • How did this process vary?
techniques. In the intervention arm, dentists were pro-
vided with a set of evidence-based preventive protocols
to apply [38]; control practices provided usual care. The B. Ethics approval and ethical issues
MPP protocols used in the RCT guided dentists to sys- In our experience, medical researchers are often con-
tematically apply preventive techniques to prevent new cerned about the ethics oversight process for such a
tooth decay and to arrest early stages of tooth decay in flexible, unpredictable study design. We managed this
their patients, therefore reducing the need for drilling process as follows. Initial ethics approval was obtained
and filling. The protocols focused on (1) primary pre- from the Human Research Ethics Committee at the Uni-
vention of new tooth decay (tooth brushing with high versity of Sydney. In our application, we explained
concentration fluoride toothpaste and dietary advice) grounded theory procedures, in particular the fact that
and (2) intensive secondary prevention through profes- they evolve. In our initial application we provided a long
sional treatment to arrest tooth decay progress list of possible recruitment strategies and interview
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questions, as suggested by Charmaz [15]. We indicated analysed. Sampling must thus begin purposively, as in any
that we would make future applications to modify our qualitative study. Participants in the previous MPP study
protocols. We did this as the study progressed - detailed provided our population [27]. The MPP included 22 pri-
below. Each time we reminded the committee that our vate dental practices in NSW, randomly allocated to either
study design was intended to evolve with ongoing modi- the intervention or control group. With permission of the
fications. Each modification was approved without diffi- ethics committee; we sent letters to the participants in the
culty. As in any ethical study, we ensured that MPP, inviting them to participate in a further qualitative
participation was voluntary, that participants could with- study. From those who agreed, we used the quantitative
draw at any time, and that confidentiality was protected. data from the MPP to select an initial sample.
All responses were anonymised before analysis, and we Then, we selected the practice in which the most dra-
took particular care not to reveal potentially identifying matic results had been achieved in the MPP study (Den-
details of places, practices or clinicians. tal Practice 1). This was a purposive sampling strategy,
to give us the best possible access to the process of suc-
C. Initial, Purposive Sampling (before theoretical sampling cessfully implementing the protocols. We interviewed all
was possible) consenting staff who had been involved in the MPP
Grounded theory studies are characterised by theoretical (one dentist, five dental assistants). We then recruited
sampling, but this requires some data to be collected and 12 patients who had been enrolled in the MPP, based
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Figure 1 Study design. file containing a figure illustrating the study design.
convenient to them such as the dental practice, commu- category of “seeking out evidence” from other focused
nity centres or the participant’s home. codes, such as “gathering and comparing peers’ evidence
Two initial interview schedules were designed for each to reach a conclusion”, and we understood the relation-
group of participants: 1) dentists and dental practice ships between them. Using this constant comparative
staff and 2) dental patients. Interviews were semi-struc- method (see Table 1), we produced a theoretical code:
tured and based loosely on the research questions. The “making sense of evidence and constructing knowledge”.
initial questions for dentists and practice staff are in This code captured the social process that dentists went
Additional file 1. Interviews were digitally recorded and through when faced with new information or a practice
professionally transcribed. The research location was challenge. This theoretical code will be the focus of a
remote from the researcher’s office, thus data collection future paper.
was divided into two episodes to allow for intermittent
data analysis. Dentist and practice staff interviews were Memo-writing
done in one week. The researcher wrote memos Throughout the study, we wrote extensive case-based
throughout this week. The researcher then took a memos and conceptual memos. After each interview,
month for data analysis in which coding and memo- the interviewer/researcher (AS) wrote a case-based
writing occurred. Then during a return visit, patient memo reflecting on what she learned from that inter-
interviews were completed, again with memo-writing view. They contained the interviewer’s impressions
during the data-collection period. about the participants’ experiences, and the interviewer’s
reactions; they were also used to systematically question
D. Data Analysis some of our pre-existing ideas in relation to what had
Coding and the constant comparative method been said in the interview. Table 3 illustrates one of
Coding is essential to the development of a grounded those memos. After a few interviews, the interviewer/
theory [15]. According to Charmaz [[15], p46], ‘coding researcher also began making and recording compari-
is the pivotal link between collecting data and develop- sons among these memos.
ing an emergent theory to explain these data. Through We also wrote conceptual memos about the initial
coding, you define what is happening in the data and codes and focused codes being developed, as described
begin to grapple with what it means’. Coding occurs in by Charmaz [15]. We used these memos to record our
stages. In initial coding, the researcher generates as thinking about the meaning of codes and to record our
many ideas as possible inductively from early data. In thinking about how and when processes occurred, how
focused coding, the researcher pursues a selected set of they changed, and what their consequences were. In
central codes throughout the entire dataset and the these memos, we made comparisons between data, cases
study. This requires decisions about which initial codes and codes in order to find similarities and differences,
are most prevalent or important, and which contribute and raised questions to be answered in continuing inter-
most to the analysis. In theoretical coding, the views. Table 4 illustrates a conceptual memo.
researcher refines the final categories in their theory and At the end of our data collection and analysis from
relates them to one another. Charmaz’s method, like Dental Practice 1, we had developed a tentative model
Glaser’s method [13], captures actions or processes by of the process of implementing the protocols, from the
using gerunds as codes (verbs ending in ‘ing’); Charmaz perspective of dentists, dental practice staff and patients.
also emphasises coding quickly, and keeping the codes This was expressed in both diagrams and memos, was
as similar to the data as possible. built around a core set of focused codes, and illustrated
We developed our coding systems individually and relationships between them.
through team meetings and discussions.
We have provided a worked example of coding in E. Theoretical sampling, ongoing data analysis and
Table 2. Gerunds emphasise actions and processes. alteration of interview route
Initial coding identifies many different processes. After We have already described our initial purposive sam-
the first few interviews, we had a large amount of data pling. After our initial data collection and analysis, we
and many initial codes. This included a group of codes used theoretical sampling (see Table 1) to determine
that captured how dentists sought out evidence when who to sample next and what questions to ask during
they were exposed to a complex clinical case, a new interviews. We submitted Ethics Modification applica-
product or technique. Because this process seemed cen- tions for changes in our question routes, and had no
tral to their practice, and because it was talked about difficulty with approval. We will describe how the inter-
often, we decided that seeking out evidence should view questions for dentists and dental practice staff
become a focused code. By comparing codes against evolved, and how we selected new participants to allow
codes and data against data, we distinguished the development of our substantive theory. The patients’
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interview schedule and theoretical sampling followed protocols had been very limited according to data from
similar procedures. the RCT trial.
Evolution of theoretical sampling and interview questions We also changed our interview questions based on the
We now had a detailed provisional model of the suc- analysis we had already done (see Additional file 2). In
cessful process implemented in Dental Practice 1. our analysis of data from Dental Practice 1, we had
Important core focused codes were identified, includ- learned that “effectiveness” of treatments and “evidence”
ing practical/financial, historical and philosophical both had a range of meanings. We also learned that
dimensions of the process. However, we did not yet new technologies - in particular digital x-rays and intra-
understand how the process might vary or go wrong, oral cameras - had been unexpectedly important to the
as implementation in the first practice we studied had process of implementing the protocols. For this reason,
been described as seamless and beneficial for everyone. we added new questions for the interviews in Dental
Because our aim was to understand the process of Practice 2 to directly investigate “effectiveness”, “evi-
implementing the protocols, including the conditions dence” and how dentists took up new technologies in
and consequences of variation in the process, we their practice.
needed to understand how implementation might fail. Then, in Dental Practice 2 we learned more about the
For this reason, we theoretically sampled participants barriers dentists and practice staff encountered during
from Dental Practice 2, where uptake of the MPP the process of implementing the MPP protocols. We
confirmed and enriched our understanding of dentists’ studying the process of doing prevention in private den-
processes for adopting technology and producing knowl- tal practice. All participants seemed to be revealing dee-
edge, dealing with complex cases and we further clari- ply held perspectives shared in the dental profession,
fied the concept of evidence. However there was a new, whether or not they were providing dental care as out-
important, unexpected finding in Dental Practice 2. lined in the MPP protocols. So, by sampling dentists
Dentists talked about “unreliable” patients - that is, from both intervention and control group from the pre-
patients who were too unreliable to have preventive vious MPP study, we aimed to confirm or disconfirm
dental care offered to them. This seemed to be a poten- the broader reach of our emerging theory and to com-
tially important explanation for non-implementation of plete inductive development of key concepts. Theoretical
the protocols. We modified our interview schedule again sampling added 12 face to face interviews and 10 tele-
to include questions about this concept (see Additional phone interviews to the data. A total of 40 participants
file 3) leading to another round of ethics approvals. We between the ages of 18 and 65 were recruited. Tele-
also returned to Practice 1 to ask participants about the phone interviews were of comparable length, content
idea of an “unreliable” patient. and quality to face to face interviews, as reported else-
Dentists’ construction of the “unreliable” patient dur- where in the literature [40].
ing interviews also prompted us to theoretically sample
for “unreliable” and “reliable” patients in the following F. Mapping concepts, theoretical memo writing and
round of patients’ interviews. The patient question route further refining of concepts
was also modified by the analysis of the dentists’ and After theoretical sampling, we could begin coding theo-
practice staff data. We wanted to compare dentists’ per- retically. We fleshed out each major focused code,
spectives with the perspectives of the patients them- examining the situations in which they appeared, when
selves. Dentists were asked to select “reliable” and they changed and the relationship among them. At time
“unreliable” patients to be interviewed. Patients were of writing, we have reached theoretical saturation (see
asked questions about what kind of services dentists Table 1). We have been able to determine this in several
should provide and what patients valued when coming ways. As we have become increasingly certain about our
to the dentist. We found that these patients (10 reliable central focused codes, we have re-examined the data to
and 7 unreliable) talked in very similar ways about den- find all available insights regarding those codes. We
tal care. This finding suggested to us that some deeply- have drawn diagrams and written memos. We have
held assumptions within the dental profession may not looked rigorously for events or accounts not explained
be shared by dental patients. by the emerging theory so as to develop it further to
At this point, we decided to theoretically sample den- explain all of the data. Our theory, which is expressed
tal practices from the non-intervention arm of the MPP as a set of concepts that are related to one another in a
study. This is an example of the ‘openness’ of a cohesive way, now accounts adequately for all the data
grounded theory study potentially subtly shifting the we have collected. We have presented the developing
focus of the study. Our analysis had shifted our focus: theory to specialist dental audiences and to the partici-
rather than simply studying the process of implementing pants, and have found that it was accepted by and reso-
the evidence-based preventive protocols, we were nated with these audiences.
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We have used these procedures to construct a assisted the researcher to make comparison among her
detailed, multi-faceted model of the process of incorpor- reflections, which enriched data analysis and guided
ating prevention into private general dental practice. further data collection.
This model includes relationships among concepts, con- 4. Having the opportunity to contact participants after
sequences of the process, and variations in the process. interviews to clarify concepts and to interview some par-
A concrete example of one of our final key concepts is ticipants more than once contributed to the refinement
the process of “adapting to” prevention. More com- of theoretical concepts, thus forming part of theoretical
monly in the literature writers speak of adopting, imple- sampling.
menting or translating evidence-based preventive 5. The decision to include phone interviews due to
protocols into practice. Through our analysis, we con- participants’ preference worked very well in this study.
cluded that what was required was ‘adapting to’ those Phone interviews had similar length and depth com-
protocols in practice. Some dental practices underwent pared to the face to face interviews, but allowed for a
a slow process of adapting evidence-based guidance to greater range of participation.
their existing practice logistics. Successful adaptation During data analysis
was contingent upon whether (1) the dentist-in-charge 1. Detailed analysis records were kept; which made it
brought the whole dental team together - including possible to write this explanatory paper.
other dentists - and got everyone interested and actively 2. The use of the constant comparative method
participating during preventive activities; (2) whether the enabled the analysis to produce not just a description
physical environment of the practice was re-organised but a model, in which more abstract concepts were
around preventive activities, (3) whether the dental team related and a social process was explained.
was able to devise new and efficient routines to accom- 3. All researchers supported analysis activities; a regu-
modate preventive activities, and (4) whether the fee lar meeting of the research team was convened to dis-
schedule was amended to cover the delivery of preven- cuss and contextualize emerging interpretations,
tive services, which hitherto was considered as “unpro- introducing a wide range of disciplinary perspectives.
ductive time”. Answering our research questions
Adaptation occurred over time and involved practical, We developed a detailed model of the process of adapt-
historical and philosophical aspects of dental care. Parti- ing preventive protocols into dental practice, and ana-
cipants transitioned from their initial state - selling lysed the variation in this process in different dental
restorative care - through an intermediary stage - learn- practices. Transferring evidence-based preventive proto-
ing by doing and educating patients about the impor- cols into these dental practices entailed a slow process
tance of preventive care - and finally to a stage where of adapting the evidence to the existing practices logis-
they were offering patients more than just restorative tics. Important practical, philosophical and historical
care. These are examples of ways in which participants elements as well as barriers and facilitators were present
did not simply adopt protocols in a simple way, but during a complex adaptation process. Time was needed
needed to adapt the protocols and their own routines as to allow dentists and practice staff to go through this
they moved toward more preventive practice. process of slowly adapting their practices to this new
The quality of this grounded theory study way of working. Patients also needed time to incorpo-
There are a number of important assurances of quality rate home care activities and more frequent visits to
in keeping with grounded theory procedures and general dentists into their daily routines. Despite being able to
principles of qualitative research. The following points adapt or not, all dentists trusted the concrete clinical
describe what was crucial for this study to achieve evidence that they have produced, that is, seeing results
quality. in their patients mouths made them believe in a specific
During data collection treatment approach.
1. All interviews were digitally recorded, professionally
transcribed in detail and the transcripts checked against Concluding remarks
the recordings. This paper provides a detailed explanation of how a
2. We analysed the interview transcripts as soon as study evolved using grounded theory methodology
possible after each round of interviews in each dental (GTM), one of the most commonly used methodologies
practice sampled as shown on Figure 1. This allowed in qualitative health and medical research [[8], p47]. In
the process of theoretical sampling to occur. 2007, Bryant and Charmaz argued:
3. Writing case-based memos right after each inter-
view while being in the field allowed the researcher/ ’Use of GTM, at least as much as any other research
interviewer to capture initial ideas and make compari- method, only develops with experience. Hence the
sons between participants’ accounts. These memos failure of all those attempts to provide clear,
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mechanistic rules for GTM: there is no ‘GTM for Received: 17 June 2011 Accepted: 9 September 2011
Published: 9 September 2011
dummies’. GTM is based around heuristics and
guidelines rather than rules and prescriptions. More- References
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Cite this article as: Sbaraini et al.: How to do a grounded theory study:
a worked example of a study of dental practices. BMC Medical Research
Methodology 2011 11:128.