Shauver, Melissa J. M.P.H.; Chung, Kevin C. M.D., M.S.
The rise of evidence-based medicine has prompted plastic surgery to reexamine the introduction and incorporation of innovative research methodology to this specialty. Unlike other specialties, in which mortality can be used as the ultimate indicator, plastic surgery has a distinct disadvantage when it comes to measuring objective outcomes. The marriage of art and science that makes plastic surgery so unique also makes quantification of the results difficult. The experiences of our patients are, nonetheless, important to explore to help the continual efforts toward improving care.
The use of patient satisfaction as an outcome metric in both the reconstructive and cosmetic avenues of the plastic surgery field is gaining popularity; however, because there are no validated plastic surgery satisfaction questionnaires, most of those used are ad hoc tools and consist of only a few questions.1 These methods of measuring patient satisfaction and quality of life raise an abundance of questions. Perhaps the most vexing question is, What does it all mean? Inventories and questionnaires, which often use five-point Likert scale response choices, can provide a wealth of knowledge, but these response scales may obscure the richness of a patient's medical experience (e.g., issues regarding breast reconstruction choices or a parent's struggle in deciding whether to proceed with reconstruction for giant melanocytic nevus).2 Qualitative research provides “color” to the “black and white” of quantitative research.
Quantitative methodology can indicate that patients are merely “somewhat satisfied” with the amount of preoperative information provided, but it cannot explain why patients feel this way or what to do about it. Furthermore, quantitative methodology is often inadequate for exploring emotional or complex issues such as how patients make decisions or their feelings about outcomes.3 Qualitative methodology is ideal for exploring these complex topics. Patients are allowed to express their thoughts and feelings, rather than simply checking a box. This “in their own words” concept is central to qualitative research.3
QUALITATIVE RESEARCH IN PLASTIC SURGERY
An informal MEDLINE search revealed that there have been relatively few published qualitative studies of plastic surgery topics. Of the 11 studies we identified, eight pertained to breast surgery, primarily breast reconstruction after mastectomy.4–11 Only three of the 11 qualitative studies were published in surgical journals: one each in Annals of Plastic Surgery, British Journal of Plastic Surgery, and Plastic and Reconstructive Surgery.9,11,12 The rest were published in nursing, psychiatric, or psychology journals. Clearly, there is a need to bring qualitative methodology to a variety of topics, both reconstructive and aesthetic, in the plastic surgery specialty.
However, planning a qualitative study can be daunting; it is completely different from planning a quantitative study. Data collection takes much more time than administering a survey. Special training may be needed to collect the data. The results are often not immediately apparent and the data analysis can be difficult. The whole process is time-consuming. However, when well executed, the results can bring far more insight into the patient experience than any other form of research.
The goal of this article is to provide a practical overview of qualitative methodology. This is by no means an exhaustive exploration of the topic. Qualitative methodology is deeply rooted in theory and covering each of these theories is beyond the scope of this article.
CLINICAL QUESTIONS SUITABLE FOR QUALITATIVE METHODOLOGY
Qualitative research is ideal for exploring psychosocial issues of plastic surgery, such as patient satisfaction. This methodology cannot predict patient satisfaction, but can help explain why a particular patient is satisfied.13 Qualitative research is also helpful for exploring complex issues surrounding a patient's decision to undergo elective cosmetic surgery or to better understand how patients and their families make treatment decisions. Another possible qualitative topic could be experiences during recovery from surgery. Any issue that cannot easily be quantified, or about which little is known, is a good candidate for qualitative research.
The development of qualitative research questions is undertaken following one of many theories. There are many theories on which to base one's qualitative research project, many more than can be examined in this article. We will focus instead on grounded theory, the theory we have the most experience with and find to be most useful in clinical research.
The main tenet of grounded theory is that the “truth” will unfold as the data are analyzed.3 This means that data collection is begun with no hypotheses. There is certainly an aim, but there are no preconceived notions about what the data will reveal. A hypothesis about how certain concepts interact and relate to one another is allowed to emerge through the process of data analysis. This hypothesis can be tested using quantitative methods. This leads to a cycle between qualitative and quantitative research (Fig. 1). Qualitative research leads to hypotheses, which can be tested with quantitative research. The findings from quantitative research may lead to answers but more likely lead to additional research questions, which can be further explored with qualitative research.
Qualitative methodology can also be used to provide more detail to a theory that has been tested using quantitative methods. This can make the theory more compelling by adding personal insights to make the theory more human.
TYPES OF QUALITATIVE RESEARCH
Data collection in qualitative research can take two distinct forms: observation and interaction.14 Observational research, such as ethnography, is the wheelhouse of cultural anthropology, providing rich information about the interactions and relationships of a particular family, professional, or social group. Observational research has the flavor of “a fly on the wall” analogy, in which the observer passively records the interactions among the study subjects to distill the dynamics of these exchanges into understandable concepts. This methodology is rooted in social science theories, and its utility to clinical research is limited. Thus, we will focus this guide on interactional research: interviews and focus groups.
One-on-one interviews make up the bulk of qualitative research. Speaking individually with participants, either in a structured or unstructured manner, allows for follow-up questions and elaboration that a survey simply cannot provide. Interviews are a good way to discover potentially modifiable factors for improving the patient experience.15 The level of detail that emerges is determined by the “structuredness” of the interview (Fig. 2).
Structured interviews take the form of a series of open-ended survey questions, allowing participants to respond freely, but with only limited follow-up.16 In these types of interviews, the interviewer asks participants ordered questions from a prepared list. Questions may require some follow-up comments, but the interviewer does not allow the participant to venture off-topic. Structured interviews are useful for drawing out details on a topic for which much is known rather than for exploring new topics. They are also appealing when specific information is desired, because the interviewer controls the flow of the discussions.
Semistructured interviews allow for much more elaboration than structured interviews but still allow the interviewer to introduce the topics. An interview guide is developed that lists the topics to be covered and possible questions to pose.16 Participants are almost always probed to see whether they have more information to provide after they finish responding. Participants are also allowed to digress to a certain degree. Often these digressions contain useful information or can spawn additional questions.
The balance of the ability of participants to discuss matters that are important to them and interviewer control make semistructured interviews a favorite among researchers for virtually any type of research question. We recently completed a qualitative study of the recovery experience following type IIIB or IIIC tibial fracture in which we used semistructured interviews.17 We developed our interview guide to cover topics such as injury information; physical recovery; the injury's effects on work, social, and family life; and questions about participants' experiences with medical care. The interviewer began the interview with the general question, “Could you please tell me a little bit about your lower leg injury, such as how and when it occurred?” Participants would respond to this question and often provide information that led to additional questions in the interview guide, but not necessarily in the order we had intended. The interviewer ensured that all topics were covered while allowing the participants to talk about other topics related to their injury that interested them, which included some topics that we did not anticipate. Several participants mentioned the increased difficulty with sexual activity following their injury. Through the use of semistructured interviews, we discovered topics that we would not have thought to include in the interview guide.
Unstructured interviews, as the name would imply, are simply free-form discussions, bordering on casual conversation. The interviewer prepares a general question that describes the overarching research concept and then allows the participant to respond and talk about any topics they choose.16 The interviewer responds to lulls in the conversation as any interested listener would, asking the participant follow-up questions but never introducing a new topic. Unstructured interviews are useful when there is little known about a topic.
Although the focus group technique was conceived by a social scientist,18 this method quickly became a powerful tool of marketing departments everywhere. However, whether for marketing or for medicine, the focus group technique takes similar form. A focus group is essentially a group semistructured interview involving six to 12 members of the population in question who gather and are led by a moderator through a discussion of a particular topic. The idea of focus groups is that group members will talk among themselves and feed off of each other's ideas and input. The moderator keeps the discussion focused and ensures that all participants get a chance to speak and that the group is not being dominated by one person. Focus groups can be used to identify popular views on health care issues or community interventions.15
ANALYZING QUALITATIVE DATA
Regardless of which data collection technique is used, interviews or focus groups should be audio or video recorded. This allows the interviewer to minimize note-taking to focus attention on the participant for a more conversational feel. This can put the participant at ease, resulting in richer detail. After the framework of grounded theory, data analysis should take place in a stepwise fashion3 (Fig. 3). One note before the steps of data analysis are detailed: the data analysis process benefits from the participation of multiple individuals. Qualitative methodology, unlike quantitative methodology, is based on the idea that each individual researcher will lend his or her own point of view to the data. Thus, the more members of the research team who are involved in the data analysis process, the more complete the data analysis can be.
A Stepwise Approach to Qualitative Data Analysis
Step 1: Transcription
Audio or video recording of the interviews or focus groups should be transcribed verbatim, and should include all verbal filler (such as “um” or “you know”), grammatical errors, long pauses, laughter, and/or changes in tone or volume of voice. For video recordings, body language or facial expressions should be noted. If there are spots where participants are unintelligible, those should be noted as well. After transcription, each interview should be listened to by someone who did not perform the original transcription, to check for accuracy and to attempt to decipher unintelligible words or phrases.
Step 2: Open Coding
Once the transcripts are finalized, coding can begin. There are several computer programs that can help organize the transcripts and codes by combining the coding of several individuals, sorting and ranking codes, and searching for passages or key words. These programs can be extremely helpful but are often quite expensive. Unless the researcher will be performing multiple, large-scale qualitative studies, one can probably get by doing it the “old fashioned” way. For our study of lower limb trauma, we did not use a software package, so we will describe the data analysis process as we achieved it.
The first type of coding that will be done is open coding. Open coding is the process of identifying sentences or passages in the transcripts that represent the concepts of interest.19 One need not be judicious during open coding. Any passage that seems interesting should be noted; there will be an opportunity to “weed out” unnecessary information later. Open coding should be performed by as many members of the research team as possible. At least two people need to be involved in open coding. Passages of interest should be indicated in some way (such as highlighting), and the general tone of the passages should be given a memorable name, or open code.19 For instance, when a participant talked about his or her occupation or ability to work, we highlighted that passage and noted it as “work.” Some passages may fit into multiple categories; the discussion of ability to work, mentioned above, could also be noted as “physical functioning.”
The basic idea of open coding is to separate the “possibly interesting” from the “truly uninteresting.” In the next steps, we will explain how to refine the results further, but right now quantity is much better than quality. After open coding is completed, each research team member should generate a list of all the open codes they created and a few passages that best exemplify that open code.
Step 3: Creation of the Codebook
When open coding has been completed, all research team members should meet to discuss their open code list. It helps to have a white board for this process. One team member will begin by listing the open codes, followed by other team members who will add codes that do not already appear on the list. Once a large list of open codes is created, the team should discuss which codes are related, which codes can be collapsed, and which codes can be eliminated altogether.
Conceptual ordering, the categorizing and ranking of ideas, is useful when developing the codebook. This process involves listing the topics mentioned and noting how often they are mentioned. There is no need at this point to develop relationships between codes; that will take place at a higher level of analysis.20
The codes that will be included in the codebook can be found using thematic analysis, the process of noting themes among the interviews and grouping those themes into larger thematic sections.8 The codebook will take these themes and give them named codes for identification. These codes should represent the main themes of the interviews or focus groups and should apply to the majority of the transcripts. One should try to not get too specialized. The codes should be organized into categories, codes, and subcodes. For example, our qualitative study of severe tibial fractures generated three categories, 22 codes, and 14 subcodes.
After all team members have agreed on the codes, definitions of the codes need to be created. These definitions will describe what types of passages should be tagged with a code and which should not. The idea is to create definitions so clear that someone who has never seen either can sit down with a transcript and the codebook and satisfactorily code the transcript. It may take some discussion to get all group members to agree as to what should be included and excluded from each code. Code definitions need not be exhaustive, but should provide just enough detail that there is little ambiguity as to what a particular passage should be coded as. We have included a section of the codebook used for our lower limb trauma study as the Appendix.
Step 4: Focus Coding
Once the codebook has been completed, focus coding can begin. Using the rules established by the codebook, the transcripts are reread and passages that fit one of the decided-on codes or subcodes are indicated and labeled.19 All passages should be listed in a separate document with its code, identifier for transcript, and page or line number. We used Microsoft Excel (Microsoft Corp., Redmond, Wash.) for this process. Each passage was included with the code (and subcode, if applicable), participant identification number, transcript page number, and other variables for participant demographics and injury information.
After all team members have coded all transcripts, the team should meet to go through each of the passages to agree on the appropriate code. Once the research team has agreed on all passages and all codes, the actual data analysis can begin.
Step 5: Data Analysis
As we have mentioned previously, there are a host of qualitative methodology theories, and each one has its own method of data analysis. However, all of the methods share some of the same features. The first step in qualitative data analysis is content analysis. This is similar to conceptual ordering, as explained in step 3. The codes are analyzed to see which appeared the most frequently.19 This will give an idea of where to begin to look for connections between codes, either temporally or conceptually. Finally, the relationships between codes are examined. The ultimate goal of analysis is dependant on the particular qualitative methodology being used. When using grounded theory, the goal is to develop a hypothesis of how different concepts (codes) relate to each other. This will lead to the construction of a conceptual framework, detailing how the different concepts are related to one another.21 This hypothesis can then be tested, if desired, using quantitative methodology.
DISADVANTAGES OF QUALITATIVE METHODOLOGY
There are several important limitations to consider when planning or evaluating qualitative research. Although all research methods are subject to investigator bias, it is especially important in qualitative research. Any preconceived notions of what the data will reveal can influence the way the interview guide is written, the way the interviewer asks questions and directs the interview or focus group, and how the passages and codes are selected.22 However, this is sometimes seen as a positive rather than a negative. In some of the more theory-based qualitative methodologies, investigators are encouraged to explore and incorporate their biases by means of “memos” made to themselves after each participant encounter.23
To control for bias in the writing of the interview guide or in data analysis, the researcher should incorporate as many team members as possible in the development and data analysis process. An easy way to control for bias is to use an independent interviewer or moderator to conduct the interviews or focus groups. Independent professional interviewers are proficient at putting participants at ease, so that they feel they can reveal anything to the interviewer without fear of being judged. What makes participants comfortable varies from subject to subject. Participant comfort is most important when the interviewer is a member of a majority population and the participant is a member of a minority or otherwise marginalized population. If this is your situation or if your study covers especially sensitive topics, such as illicit behavior, it may be beneficial to “audition” interviewers with members of the sample population to gauge their comfort.
A good interviewer should also be firm and able to steer the conversation back on track if necessary. This is most important for focus group moderators, who must manage multiple personality types to ensure that everyone gets an opportunity to speak. Professional focus group moderators can be used, as they are well versed in this aspect of focus group management.
Another limitation to qualitative research is low generalizability. Because qualitative research seeks to closely examine the experiences of individuals, it does not lend itself to generalization to a larger population. However, this was never the intent of qualitative research.8 This methodology was intended to explore topics on a level that quantitative research cannot,3 not to speak for the entire population. However, this does not mean that because it is not generalizable, there is nothing to learn from qualitative research. The “roadmap” that is formed by qualitative data analysis helps surgeons to navigate similar situations.24
INTERPRETING AND DERIVING EVIDENCE FROM QUALITATIVE RESEARCH
Are the Results Valid?
Validity takes on a different meaning in qualitative research. Statistical validity refers to how closely one's research results reflect reality. However, qualitative research is performed with the belief that everyone has his or her own reality and that all these realities are “correct.”25 The presence of multiple realities makes it rather difficult to apply the statistical definition of validity, which presumes a singular reality.
Rather than judge the statistical validity of a qualitative study, it would be more beneficial to instead judge the rigor with which the study was performed. After systematic reviews discovered that articles describing qualitative studies rarely report all factors that affect readers' ability to critically assess the results, Tong et al. developed the Consolidated Criteria for Reporting Qualitative Research to guide researchers through the qualitative writing process.15 The criteria include a 32-item checklist that covers factors related to the research team, study design, analysis, and findings (Table 1). When planning a study, using this checklist can ensure that the research will be as rigorous as possible.
Can the Results Be Applied to My Patients?
Qualitative research can provide rich detail that quantitative research simply cannot. Using grounded theory, researchers can use these details to develop a hypothesis that can then be tested using quantitative methodology. However, perhaps the goal is not to inspire further research but to directly improve the experiences of patients. Applicable items can be discovered from direct questions (“What would make your experience better?”) but can also be found in the responses to other, often unrelated questions. In our study of lower limb trauma, we asked participants whether there was anything the medical staff could have done to improve their recovery experience. Patients almost always responded that there was not, or gave a superficial response such as softer beds or prettier nurses. However, during data analysis, we found that several participants who had undergone amputation felt that the doctors were too busy to respond to their questions, so they just did not ask. These participants reported that it would have been nice to discuss practical, and emotional, issues with someone who had a similar experience. These were the same patients who responded that they felt nothing was missing from their recovery experience, but clearly there was some way in which the ancillary medical staff such as counselors could have been helpful. Careful data analysis will allow us to “read between the lines” of simple responses to find what is truly important to patients.
As the practice of medicine moves more into the realm of a patient-centric approach, patient satisfaction will become more important than ever. The use of qualitative methodology can take the traditional five-point Likert scale survey to a more insightful level. Qualitative methods can help plastic surgeons to better understand the desires and needs of their patients to continue the ultimate goal to deliver the best care possible.
This works was supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to K.C.C.).
Physical and Mental Health
Physical functioning (including work, sports, everyday activities)
Change: Any comparison of before and after the injury or during recovery
Pain: Any mention of physical pain
Energy (including work, everyday activities, social activities, sports)
Work: Discussion of job, job or career changes caused by injury, or inability to work
Impact on family: Any mention of spouse or children (excludes emotional support)
Social life: Any mention of friends or social or sports activities
Emotional effects: All feelings, including depression and frustration
Body image: Discussion of mental discomfort with scars or prothesis, gained weight
Self-image: Not physical or body image related
Other people's perceptions: Any mention of the actions or comments of others
Overall life effects: Overarching comments, everyday thinking or positive outcomes
Coping: Any comment related to mental/emotional coping or dealing with the injury
Acceptance: Example: “What can you do?” or “That's just the way it is”
Anger: Anger at circumstances or cause of injury
Denial: Denial of emotion related to injury
Family support: Any mention of emotional support derived from family members
Grateful (e.g., “I'm just happy to be alive” or “I could have been hurt a lot worse”)
Humor: Any comments about jokes participant makes about their injury appearance or physical ability
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