Making use of qualitative research techniques.

Consider the following situation: You have recently taken on administrative responsibilities at a new hospital where you are responsible for improving patient care programs and organizational efficiency in the general medicine outpatient clinics. You are familiar with your department's general objectives for change and with theoretical strategies for improving operations, but you want to optimize the transitions for all involved parties. In early meetings, department and hospital staff express skepticism that any of the anticipated changes would serve them or the hospital's patients better. In this situation, immediate action—such as announcing a new clinical or quality review program—would directly address the challenges you face. But more information might help you more effectively meet your professional responsibilities. You might want to learn what systems already work well in the clinics, or better understand what services would be valued in the local community. You might also want to learn about employees' perceptions of their mission and service to identify strategies that could motivate them for change. The information to help you meet these objectives will come primarily from the people involved in your questions and plans—your patients and coworkers, for example. One can gather this information by talking to people informally. Alternatively, one can use qualitative research techniques for this purpose, particularly in new situations and environments. This article addresses how and why busy clinicians might use qualitative techniques to answer questions and solve problems like those in the scenario above. Qualitative research is a form of inquiry that analyzes information conveyed through language and behavior in natural settings.1 It is used to capture expressive information not conveyed in quantitative data about beliefs, values, feelings, and motivations that underlie behaviors. Qualitative methods derive from a variety of disciplines and traditions.2 They are used to learn directly from patients and others what is important to them, to provide the context necessary to understand quantitative findings, and to identify variables important for future clinical studies. Although qualitative inquiry has been championed as a way of “reaching the parts other methods cannot reach,”3 it is also distrusted by some because it rarely provides a generalizable foundation for clinical decisions and policies.4 Readers are referred to several recent editorials for overviews of these differences and proposals for their reconciliation.3–7 Some qualitative approaches use technical methods (such as statistical content analysis) to determine the significance of findings, while others rely on researchers thoughtful reflection. Ethnography is a form of inquiry that can combine these approaches, and we will use techniques from this tradition to illustrate our points. Ethnography is a semistructured way of learning about people and their culture.8 With specific questions in mind, ethnographic researchers immerse themselves in an environment to discover the meanings, conventions of behavior, and ways of thinking important to individuals of a group as they emerge in unrehearsed encounters.Table 1)outlines some of the techniques investigators use in this process. Table 1 Examples of Qualitative Techniques Ethnographers' essential task is to observe study subjects in their natural settings. They can do so as silent background observers or as “participant-observers” who ask questions as they accompany study subjects in their activities. In either role they collect data in both unstructured and structured ways. They can write spontaneous “field” notes that detail what they see and hear, or organize their observations around categories, checklists, or rating scales that they bring to the setting. Beyond observing, ethnographers interview subjects with one or more objectives in mind: to learn from well-positioned individuals who can provide useful information (also called “key informant” interviews); to understand experiences especially important to shaping perceptions and decisions (“critical incident” reports); or to generate new information from groups of subjects in focus groups. Audiotaping or videotaping these interactions helps guarantee that expressive data are captured accurately and completely as they emerge. Taping also permits the researcher to carry the data to more controlled settings, where they can be transcribed, coded, analyzed for important themes and meanings, and verified using trained evaluators (aided by computer software if appropriate).2 The use of more than one evaluator helps ensure the reliability of ethnographic data, as does a detailed accounting of how a study analysis is performed. Researchers can be reasonably assured of the validity of their findings by collecting data from independent sources, presenting preliminary findings to study participants for their feedback, and fully examining unusual or “outlying” information. These strategies are likely to become increasingly standardized as consensus emerges around the need for greater methodologic rigor in qualitative research.9, 10 These methods are appropriate for practical situations in which a fuller understanding of behavior, the meanings and contexts of events, and the influence of values on choices might be useful for physicians (Table 2) We describe below how ethnographic techniques might be used to gather information necessary to plan and implement administrative changes in a clinical setting. Table 2 Professional Challenges for Which Qualitative Approaches Could Be Useful