Growing Quality in Qualitative Health Research

Abstract

Qualitative methodologies are growing in popularity in health research; however, the integration of these methodologies into the clinical context is not always straightforward. In this article the author discusses some of the paradigmatic and methodological tensions that characterize the use of qualitative methodologies in clinical health research and showcase one solution to these tensions. The McGill Qualitative Health Research Group is a scholarly group of qualitative health researchers working together to advance a qualitative research agenda in clinical disciplines.

Qualitative methodologies have grown in popularity in health research fields over the past decade. Although increasing numbers of investigators and students are opting for qualitative approaches to addressing clinical problems, qualitative health research still struggles for legitimacy in many academic health institutions in Canada.

Making the argument for why qualitative research is needed for advancing understandings of health phenomena does not require rocket science; Einstein himself is credited with saying “Not everything that can be counted counts, and not everything that counts can be counted” (cited in McKee, 2004), yet health care institutions remain underpinned by a definition of research that rests firmly in the paradigm of clinical science. This is especially true in institutions such as hospitals, where research is generally judged by objectivist criteria and where unconventional versions of truth and method are often regarded with suspicion and reservation.

A number of issues characterize the division between qualitative and quantitative research in health settings. First and foremost is the place of objectivity in understandings of scientific research. Some qualitative researchers have chosen to respond to this tension by moving away from the jargon of research entirely, instead adopting the label qualitative inquiry. Others have addressed this issue by shifting away from the language of science. They instead stress the research aspect of qualitative research; that is, research as the systematic investigation of a given phenomenon, the goal of which is to advance knowledge. As such, this definition of research does not hinge on science or objectivity; instead, it requires only an assessment of the rigor of the investigation. Following this commitment to research has been a flurry of publications outlining the criteria required to ensure the rigor of qualitative health studies.

Another major issue in this tension is what is called, in the jargon of clinical research, the “So what?” factor. To answer the So what?, a research project must explicitly address how clinical practice and patient outcomes will be positively affected by study findings. This So what? has been elevated to the status of an ethical requirement for clinical research. Together with coauthor Carnevale, we have taken up this issue elsewhere (Macdonald & Carnevale, 2008), where we parsed the discussion into two issues, the ethics of supporting the production of knowledge as a means to an end and the ethics of supporting knowledge as an end in itself. We argue that there is a moral imperative to support both to advance health knowledge.

Further challenges include determining which qualitative methodology should be employed for a given health issue. Determining the “which” is often poorly assessed by institutional gatekeepers in health care institutions. Scientific review committees and research ethic boards, for example, often have limited experience with qualitative research, and as a result a generic “qualitativeology” approach permeates research assessment, lacking a sophisticated understanding of the numerous individual methodologies (e.g., grounded theory, phenomenology, ethnography) and the respective criteria for rigor required by each.

Another tension that exists with research design is around the concept of a research protocol. The word protocol originally comes from Greek, referring to sheets of papyrus literally glued together. The intent of a clinical protocol is to outline the research design and process, and once approved, is not open for adaptation or interpretation; a clinical research protocol does not change or evolve once the study begins. In contrast, many qualitative methodologies are iterative and include creative components such that their design can be drafted but not completely predetermined before data collection begins. ¹

Although these and many other tensions continue to characterize the development of qualitative health research in clinical contexts, encouraging advances have also been made over the past decade, and many overtures have been made to include qualitative projects in health research contexts. One example is the rise in popularity of the mixed-method methodology. Another is the increased interest in qualitative projects by funding agencies such as the Canadian Institutes of Health Research (CIHR), where qualitative proposals are actively solicited and peer reviewers with expertise in qualitative methodologies are becoming more common.

Responding to these tensions and aspiring to contribute to their resolution, a number of scholars working in clinical settings in Montreal, Quebec (Canada), came together to form the McGill Qualitative Health Research Group (MQHRG) in 2003. The original intention of the MQHRG was to create an academic environment for qualitative health research across the McGill University Health Centre to productively engage these tensions and to support qualitative research in health care settings. Six years later, MQHRG has an active interdisciplinary and interprofessional membership, with over 90 researchers and students on the group listserv. Although “McGill” remains as part of the title, membership has grown to include the four Montreal universities, with formal and informal ties to a number of qualitative research groups and scholars from across Canada as well as South America and Europe. The MQHRG is also a Collaborating Site of the International Institute of Qualitative Inquiry. Thanks to this impressive growth, the MQHRG has been recently welcomed into the McGill Centre for Medical Education.

The MQHRG meets bimonthly, with the 2-hour meetings convened around a variety of topics. For example, our meetings might focus on brainstorming methodological challenges in conducting qualitative health research, designing research projects, sharing research findings, providing a friendly peer review for the dry run of a graduate thesis defense or conference presentation, or critically engaging a new research methodology or theory.

This issue of the IJQM showcases three articles written by a variety of MQHRG members. These articles have grown out of presentations from the 2007 MQHRG conference, Ensuring Quality in Qualitative Health Research. The objectives of this conference were three-fold: (a) to increase the visibility of the MQHRG in the Montreal community, (b) to showcase outstanding qualitative health research being conducted in Montreal, thereby providing a place for the dissemination of research results as well as innovative research methodologies, and (c) to push the qualitative health research agenda in the direction of critical, rigorous inquiry.

To fulfill these objectives, this half-day conference was convened in a central McGill location (the David Thomson House Graduate Student Centre) and open to the public thanks to funding from the Palliative Care Program of the Montreal Children's Hospital (McGill University Health Centre), and a small grant from the Sociobehavioural Cancer Research Network, of the former National Cancer Institute of Canada, now the Canadian Cancer Society Research Institute. The agenda was specifically designed to focus on methodological issues in conducting qualitative research in clinical contexts. The morning began with research presentations, the presenters hand-picked from a variety of disciplinary backgrounds, including communications, education, medicine, nursing, dentistry, and oncology/whole person care. They also represented a range of experiences, including graduate studies, postdoctoral training, clinical practice and academic teaching. The research presentations were followed by a panel discussion on methodological rigor and how to mentor students in research methodologies that go “against the grain” of conventional health research. Panelists were from education, nursing, biomedical ethics, and social work. ² We finished the day with an open discussion about future directions for qualitative research and specifically what would be required to help push the agenda at the institutional level.

This conference was the first conference on qualitative health research ever held at McGill University. The audience included an extensive interdisciplinary and interprofessional mix, with 50 individuals representing 23 disciplines: from the humanities and social sciences (e.g., anthropology, communication studies, and psychology), medical and allied health sciences (e.g., genetics, geriatrics. neurosurgery, nursing, occupational therapy, psychiatry, and social work), and health research professions such as research ethicists. Conference evaluation forms were completed by over half the participants, with overwhelmingly positive feedback and creative ideas for future symposia.

The three MQHRG articles in this issue of IJQM provide a sampling of the methodological issues raised at our conference. For example, Allen and Hutchinson discuss the challenge of being true to the foundations of a research approach when working with participants whose health status limits their ability to engage with the research process. They reflect in their paper on how their commitment to working with participatory action research (PAR) was challenged by the needs of their participant-collaborators with end-stage renal disease as well as by normative performance indicators required by academic institutions. Their paper inspires us to think about when is PAR really PAR, and about creative solutions to working towards social action in the face of personal and institutional challenges.

The paper by Jagosh and Boudreau highlights an important methodological issue for qualitative health research in bilingual settings. These authors write about the humbling experience of running into serious methodological challenges, in their case the non-transferability of language. In this process the authors discovered how such challenges can invite the researcher to question presuppositions about their own theoretical frame as well as about the inherent limitation of research instruments.

Hunt, Chan, and Mehta offer practical advice for qualitative research trainees. These three authors are all clinicians by training but are writing from the perspective of graduate students working “against the grain” on qualitative health projects within traditionally postpositivist applied health disciplines. The lessons they have learned along the way should bring an awareness to other students as well as help graduate student supervisors to anticipate some of the challenges students may face in their research endeavors.

Together, these articles are a testament to the rigorous and thought-provoking scholarship emerging from qualitative researchers working in clinical settings. It is with much pleasure and pride that we offer them for the readership of the International Journal of Qualitative Methods.