The Art of Qualitative Research

The Art of Qualitative Research A Short Guide for Dentists Faaiz Alhamdani, PhD Design and technical supervision ENANA For Information Technology www. ENANA.com All rights reserved to the author No part of this book may be reproduced, saved in any form or by any means without prior permission in writing of the author Second Edition 2023 2 “Everything we see is a perspective, not the truth” Marcus Aurelius, (121 AD180- AD) 4 Table of Contents 7 Introduction 9 Importance of qualitative research 11 Using fine art as an analogy for qualitative studies 14 The philosophical basis for qualitative research 21 Sampling for qualitative study design (Number of participants) 23 Data collection in qualitative research 27 Data analysis (making sense of qualitative data) 37 Common qualitative methodologies in health studies 39 Thematic analysis 42 Hypothetical study scenario 43 Grounded Theory 47 Hypothetical study scenario 48 Generic qualitative research methodology 51 Phenomenology 54 Hypothetical study scenario 55 Interpretive (Hermeneutic) phenomenology 58 Hypothetical study scenario 59 Writing a qualitative research paper 61 References 5 Acknowledgment It has been a long journey with this book, and I have to thank people who accompanied me in this journey. I have to start with the supervisory team at Newcastle University where I studied my PhD. They introduced me for the first time to the Qualitative Research; the first and foremost is Prof. Justin Durham who guided me at the beginning of this voyage. I awe him greatly. I would like to thank Dr. Ian Corbett who was the best mentor during the PhD study. I also would like to extend my thanks to Prof. Catherine Exley who encouraged me and fueled my passion toward this field of knowledge. I would like to express my thanks to the President of Ibn Sina University Prof. Abbas Alsharifi. My deep gratitude to the Vice Presidents for both Administrative and Scientific Affairs (Prof. Basim Shehab, and Asst. Prof. Sinan Bahjat) for their support and efforts to make the publication of this book a dream come true. The last but not least, I would like to thank my family for their continuous support, and my dear friend Dr. Ali Zayni who supervised the design of the book to the level I am really proud of. Faaiz Alhamdani, PhD Baghdad, 2023 6 Introduction Qualitative research aims to reach a better understanding of human perceptions, views, experiences, and interactions with social phenomena [1]. Recently, there is more appreciation for the role of qualitative research in the field of healthcare [2], as it provides health researchers with a holistic view of the complexities of different health problems. Qualitative studies are more endorsed by the nursing research field [3,4]. This can be attributed to the close encounter of nurses with patients in hospitals and care homes. This gives academics who work in the nursing field a unique opportunity to deal with different patient’s views and experiences with a wide array of health situations. The same applies to psychological research [5,6]. Psychologists work closely with their patients to understand and comprehend their problems with their inner and outer environments. This close relationship helps patients to elaborate on their fears, concerns, and experiences with troublesome feelings. Despite dentists enjoy an intimate professional relationship with their patients compared to their fellow physicians, they do not seem to deal with qualitative research with the same passion. Dentist- patient relationship transcends the close physical encounter during dental sessions. It is more rooted in shared decision-making. Patient’s opinions of their facial appearance reflected by their dental and oral health play a major role in the dental treatment outcome. For the above reasons, this short guide aims to bridge the gap between dental health practitioners, as well as, dental academics, and qualitative research. This book will oversimplify the qualitative research paradigm using fine 7 art examples to help dental researchers overcome the burden of long textual explanations for qualitative research philosophy and the most widely adopted methodologies in health research. This short guide does not aim to discuss in detail each methodological approach nor the trustworthiness of qualitative research findings. Its main goal is to highlight the general characteristics of qualitative research as a concept and as practice for each methodological approach 8 Importance of qualitative research The more advances we achieve Keynote: in the bio-medical field the more Disease process, is questions we ask. As we attempt to a two sided story. answer these questions we assume Qualitative research (hypothesize), and we test our is our tool to discover assumption (hypothesis testing). the patient’s side of Hypothesis testing is the core of this story. modern health science’s research. Hypothesis testing in the experimental condition is the essence of the quantitative research tradition. Despite that quantitative research represents the mainstream approach in biomedical sciences [7]. However, there are two issues need to be considered in biomedical research. In quantitative research, the patient’s health problem is seen from our assumption not according to theirs. Patient’s views and assumptions do not lie within the paradigm of quantitative research. Patient’s perception, experience is the essence of qualitative research. Qualitative research aims to understand humanrelated phenomena within the patient’s life context not in an experimental context, as in quantitative research [8]. It seeks to explain and understand rather than quantify or predict. The second issue is related to hypothesis testing itself. Testing hypotheses in quantitative research tradition assumes certain background knowledge about a given aspect of a health problem. When we have no clear understanding of the problem under question quantitative research is not justifiable, because we do not have a hypothesis to test. 9 Here comes the importance of qualitative research, as it seeks to explore areas of health phenomena with little or no available information about. It provides knowledge about unknown areas in patient’s experiences, views, and concerns toward their health, and their expected outcome [10 ,9]. It is true that quantitative randomized clinical trials (RCT), systematic reviews, and meta-analysis research lie at the top of the hierarchy of evidence-based medicine [12 ,11]. However, they cannot provide a better understanding of the bio-psychosocial impact of a health condition on patient’s daily life and the influence this impact might have on the shared decision-making process [13]. This knowledge is important within the context of the shared decision-making process. In clinical practice, shared decisions between the dentist and the patient is crucial within the environment of medical consumerism. As the goal of dental care, as general medical care, is to improve healthrelated quality of life. Hence, there is an increasing consensus on the importance of the patient’s perspective regarding their health. This perspective is more vital regarding dental treatment outcomes [14]. Qualitative research helps the dentist visualize the patient’s side of the health problem. This cannot be achieved using quantitative research methods. Most importantly, it encourages better dentist-patient communication. Fruitful dentistpatient communication lies at the heart of dental practice. This cannot be fully achieved without qualitative studies. 10 Using fine art as an analogy for qualitative studies It is risky to write a short guide on Keynote: qualitative research, especially by a The process of researcher does not have an academic understanding the patient’s sociological background. This means experience, views, that the writer is stepping outside thoughts has a clinical researcher’s comfort zone. creative side. It is Clinical researchers who are used to like the process of understanding dealing with numbers and statistical a painting or any values find it difficult to assert their other art work. management on patient’s subjective accounts of the disease process. Many clinicians find qualitative studies as an alien territory [15]. Despite the recent attention toward qualitative research and a plethora of published texts on qualitative research and its methodologies [16], still, it is difficult for a clinician to be engaged with these texts. This is because qualitative studies represent a different way of research thinking. When I explain qualitative research in the way used in the published text, I find to achieve engagement with the audience. This encouraged me to choose fine art examples as a friendly medium for introduction of qualitative research. I have been involved in fine art writing for over 15 years. Real art is a true example of a rigorous quest for knowledge and understanding. That what makes masterpieces of art stood the test of time. Also, art, social science, and qualitative research share the same ultimate aim; understanding human experiences in different life situations. In addition, fine art, like science is a form of knowledge [17]. Contrary to the common belief, fine art practice does not lack rigor or defined methodological practice. 11 Furthermore, there is something common between art and qualitative research, which is creativity. Making sense of qualitative data, whether it was textual, visual, or lived experiences is an important part of qualitative research practice. For the sake of conceptualizing a given phenomenon, the researcher needs to be creative. This is, especially, seen as the researcher moves from data coding to abstracting [18]. There is another important aspect of creativity in art, which is the ability of a picture to tell a thousand words. Cresswell described qualitative research as a woven fabric with tiny threads, many colours, and different textures [19]. I can’t think of a different definition for describing a modern painting canvas. For the sake of explaining qualitative research using fine art examples, I will consider the painter as a patient expressing him/herself, and the spectator or the fine art critic would be the researcher. In this sense, imagine the painting as the qualitative data you wish to analyze. Each painting reflects a particular painter’s experience and view of a particular life event. In other words, it reflects the painter’s interpretation of a certain phenomenon. This may clarify the term “interpretivism” commonly used in qualitative research. Interpretivism opposes the term “positivism”, which represents the basis of quantitative research. Positivism stands for knowledge about a phenomenon, (physical entity) expressed by numbers or can be tested or measured [20]. Patient’s experience and understanding of a particular health problem is not a physical entity and cannot be measured. Hence it cannot be investigated using quantitative research methods. 12 When a fine art admirer finds an interesting painting for an unknown artist, at least to them, they start gathering information about an artist trying to know as much as they can about his paintings to reach an understanding to his artistic style, favorite colors, common themes and the way his creative career developed over the years. Qualitative research works the same way, as it develops concepts, explore meaning, describe multiple realities, or produces generalizable theory [21]. This gathering of information is called the “inductive approach” because the researcher does not know much about the phenomenon he is studying [8]. This “inductive approach” mostly used in qualitative research is the opposite of the “deductive” approach used in quantitative research. In quantitative studies, we test our assumptions (hypotheses) regarding the phenomenon rather than exploring a phenomenon or “generating a hypothesis ” [22]. 13 The philosophical basis for qualitative research It is useful for every researcher to know about the Keynote: Facts are either measured philosophical background of using quantitative research, scientific inquiry and related or interpreted (understood) research practice to have using qualitative research. a better understanding of what separates between the philosophical views of both quantitative and qualitative research. To achieve this understanding we need to know about the ontological and epistemological stances of both. Ontology is simply the study of being [23]. It is the nature of the world and what we know about it [24]. Reality is a human construct, which means that each one of us has their view of reality. Ontology, in this sense, asks the question; what is reality for me, and is there a reality outside what I think and believe? Ontological stances (positions) lie between two extremes: realism and idealism. Realism assumes there is an outside reality independent of our perception (outside what we think or believe). Idealism, on the other hand, states that there is no reality outside our belief or understanding. Reality is only what my perception tells me (how I look at it). In between these positions lies subtle realism which acknowledges the presence of an outside reality, but this reality is not separated from our interpretation. The ontological views could be exemplified by the following example. Imagine a group of spectators watching a movie “the outside reality”. Some spectators believe that what is happening in the movie is part of their everyday life. This is 14 “realism”. Others find what is happening in the same movie is just fiction and has no what so ever connection to their life. This exemplifies “idealism”. The last group of spectators believes what is happening in the movie is not their life, but they accept the fact that there are some events might happen or could have happened. This is “subtle realism”. Epistemology, on the other hand, is defined as the theory of knowledge [23]. If Ontology asks what we know about something, Epistemology asks how we know about it. Epistemology, also, has two extremes. The first is positivism, which states that the studied phenomena (human feelings, views, and emotions) can be independently measured and are unaffected by the researcher [25]. This position assumes that social facts can be approached in the same way as the natural world because human behavior is governed by regularities [24 ,23]. The second epistemological position is interpretivism, which states that the social world and the researcher have a mutual influence on each other and that social facts and values are influenced by the researcher’s perspective. Furthermore, since the social world is not governed by natural sciences rules (regularities), the methods of the natural sciences are not appropriate. Hence, the researcher has to explore the social world through the participant’s perspective [25]. In qualitative research, the researcher is the research instrument. They are the instrument used for data collection and data analysis at the same time. Quantitative research, on the other hand, assumes that the researcher has no influence on data collection or data analysis, because quantitative research deals with physical data, which can be observed, measured, tested, and explained by numbers and statistical values. 15 Suitable example for the difference between quantitative research and qualitative research is the difference between realistic and abstract paintings. Although, the term realism as used in painting could be misleading. Realism in painting does not refer to an ontological stance. It is a term used for a popular school of painting in the 18th century. Besides, art, cannot be separated from human emotions even in its extreme super-realistic movement. In a realistic painting, the artist tries to depict the phenomenon in an impartial way. In realistic painting, the painter is not interested in provoking any feeling rather providing the spectator with facts. He tries to be as objective as possible. (Figure 1). The artist’s position in this realistic painting could be a good example of quantitative research. The objectiveness in showing the life event as they were, not as they wish they should have been [26]. This reflects the separation between the observer and the phenomenon under study. 16 17 Figure (1): Realistic painting by Gustave Courbet Conversely, in abstractionism, there is no unified understanding of the painting, because each one, the artist and the viewer has their interpretation of the artwork. As a viewer, you will not be able to provide an objective account of the artist’s work. What you have is your interpretation against his or her interpretation (Figure 2). Figure (2) Abstract painting by Kandinsky This shows an important aspect of qualitative research thinking. Qualitative researchers are interested in the participant’s interpretations of their experiences and views of the disease process not the disease process itself. Furthermore, qualitative researchers have their interpretation for the studied phenomenon. They are the instrument for data collection and data analysis. 18 Some researchers believe that the philosophical basics of qualitative research were built on the work of twentiethcentury authors: Heidegger, Merleau-Ponty, and Habermas. These foundations were applied by anthropologists, sociologists, and recently by health care researchers [27]. Others believe that qualitative research can be linked back to the ideas of Immanuel Kant in his book (Critique of Pure Reason) published in 1781, when he proposed that “our knowledge of the world is based on ‘understanding’ which arise from thinking about what happens to us, not just simply from having had particular experience”; and Wilhelm Dilthey (1860s70-s) who emphasized the importance of ‘understanding’ and studying people’s lived experience [25]. However, the author believes that qualitative thinking lies deeper in the history of philosophy. It is evident in the philosophy of Marcus Aurelius, the stoic philosopher and Roman Emperor (121 AD180- AD) “Everything we see is a perspective, not the truth” [28]. Another important difference between quantitative and qualitative research is related to their methods. Quantitative research adopts what can be considered as a unified research approach with a certain set of statistical tests for different bio-medical studies. Besides, quantitative research, being a common practice, does not command the need to know its philosophical background. In qualitative research the issue is different. There are different schools and each school is based on different philosophical tradition. Every newcomer to the qualitative 19 research paradigm needs to know about the philosophical traditions that underpin scientific research in general and qualitative research in general and each qualitative research methodology, in particular. However, there is a current tendency in health research to rely on Thematic Analysis and Content Analysis methods. This methodological approach is more appealing to health researchers. These methods do not require deep and rigorous data analysis. Besides, they are more suitable for mixed (qualitative and quantitative) studies [29,30]. 20 Sampling for qualitative study (Number of participants) An essential difference between quantitative and Keynote: qualitative studies is the Qualitative data are human sample size. In quantitative words that reflect experiences, meanings, or views. research, the sample size is The qualitative data value is not governed by statistical rules, measured by the number of whereas qualitative research participants, but by the diversity is governed by the different and richness of their responses. meaning each individual give to the studied phenomenon. Hence it looks for the sample which provides adequate insight (depth and breadth) into people’s experience [31]. This means the researcher selects patients with different experiences employing non-probabilistic sampling “purposive sampling” strategy. This sampling approach aims to recruit participants who are likely to have different experiences and it continue requiting participants until there are no new ideas to be added to the data. This is often termed “data saturation level” [32]. It is not unusual that the researcher reaches the level of data saturation after 5 interviews only. Another type of non-probabilistic sampling employed in qualitative research is «Theoretical» sampling. In this sampling technique, the next participant recruitment is guided by data analysis (see Grounded Theory Section). This provides an extended exploration of various aspects of participant’s views for the sake of theory development [33 ,8]. A good analogy for this aspect of experience exploration 21 can be seen in modern fine art practice. The artists, as they make their exhibitions, they tend to dedicate the exhibition to a particular idea (concept) or aspect of human experience. The artist might believe the exhibition concept cannot be covered by one or two paintings. The artist might exhibit 10 ,7, or 12 paintings until the painter is satisfied the whole concept has been presented. It does not matter if this might take a few weeks or several years from the artist’s work. What matters is the idea behind doing the exhibition reaches the audience in the best possible way. 22 Data collection in qualitative research There are 3 main methods of data collection in qualitative studies: observations, interviews and focus group discussions. Other less commonly used methods include the analysis of public or private documents, & e-mails [9]. Keynote: To collect qualitative data, we talk to (interview) patients (participants) either as individuals (semistractured/in-depth interviews), group discussions (focus groups), or share with participants their environment (ethnographic studies). In the focus group (Figure 3), some purposely selected participants discuss together their personal opinions on the research topic [34]. This method has been used to explore a wide range of healthrelated problems [35]. In focus group discussions participants are encouraged to talk, exchange ideas, experiences, and points of view [36]. In this way, a focus group is thought to encourage the research participants to explore relevant issues in the group and conceptualize the research issue in the different forms of communication [36]. This method of data collection is a collective process of negotiation. It is a dynamic, interpersonal process. This is Figure (3): focus group discussion 23 why it is more commonly used by ethnographers who are looking to understand how particular cultures give meaning to phenomena reflecting symbolic interactionism [31]. Focus group discussion needs to be balanced between dominant voice personalities who tend to take on the charge of the discussion, and other shy voices. Qualitative interviews could be a better choice for data collection when personal or sensitive issues might not be appropriate to be shared in a group discussion. There are 3 types of interviews: Structured interviews, semi-structured interviews, and indepth interviews. The structured interview, which is not used in qualitative research has fixed standardized questions and the answers are from fixed choices. Quality of Life instruments (questionnaires) are examples of structured interviews [37]. Semi-structured interviews start with few open-ended questions “topic guide”. These 5 to 7 questions guide the interviewer during the interview. With this set of topic guide questions, emergent ideas can naturally be explored. In another word, topic guide questions may be followed by other questions to identify other areas of the phenomenon under study [39 ,38]. Qualitative interviews are essentially conversations that aim to understand the phenomenon from the participant’s perspective. As they use open-ended questions they explore in-depth the issues of concerns to the participant [41 ,40]. Focus group discussion is a useful data collection technique. It saves time and benefits from the participant’s interaction [,42 43]. However, it does not allow the researcher to focus on each participant separately. This will make them lose the individualistic account of each participant’s voice. That is why it is not useful for phenomenological studies. In addition, it does not allow the 24 researcher to reflect on each interview separately as in semistructured interviews. Hence, the researcher will not benefit from the data collected from the previous benefit from the data collected in the previous interview to inform the following interview. In-depth, interviews are even less structured than semistructured interviews. They begin with one or two questions and all the following questions will depend on what the interviewee will say. These questions aim to clarify and provide more depth understanding of the issue under question [37]. Open-ended questions used in qualitative research are questions Figure (4): a qualitative interview that start with “what”, “how” & “why”. This enables the interviewees (patients) to speak and elaborate on the nature of their experiences. In qualitative studies, the researcher needs to avoid, as much as possible, questions answered with “yes” or “no” [38]. Throughout the course of the interview, the topic guide questions are complemented by “probes” questions. Probes are the questions that aim to investigate further issues raised in the interview process [45 ,44]. Examples of “Probe” question; would you tell more about this; this is interesting.... can you explain what you mean exactly? “Prompt” is another qualitative interview tactic, which is used 25 to control the path of the interview. When the interviewee starts to talk about aspects of experience that seem to be irrelevant to the research subject, the interviewer may respond in the following way; “it is interesting what you have said, which we may discuss later; this is useful information indeed. However, let’s go back to what you have said earlier... etc [46]. Prompts might not be a suitable tactic to be used quite often, as the interview might reveal an important aspect of the experience, which might be overlooked by the researcher. Qualitative interviewing is not a difficult task for clinicians. During daily clinical practice, clinicians ask patients about their complaints and their relevant and medical history to reach the diagnosis. So, they are equipped to be good listeners. Besides, clinicians, as they interrogate patients about their clinical problems, they deal with different attitudes and personalities. Qualitative data are not only obtained by only audio-recorded interviews, which are “transcribed verbatim” for the aim of analysis. In ethnographic studies, the recorded data may be the researcher’s reflections of their experience as he/she shares the environment where the phenomenon is taking place. An example of such research is studying nurse’s experiences in intensive care units. Ethnographic study means studying and sharing the experience of a group of people within a specific cultural or environmental context [21]. Doing ethnographic study is like doing a TV documentary about a certain phenomenon, such as Picasso’s art. Picasso is a revolutionary artist with a versatile artistic career. Studying his art itself might not provide an in-depth understanding of his artistry. We might need to visit his home town; meet members of his family, share their living environment, and having a sense of it and how this could influence & shaped Picasso’s way of thinking. 26 Data analysis (making sense of qualitative data) Qualitative data are not numbers, nor statistical Keynote: values. Qualitative data The process of understanding could be texts, live patient’s experience, views, observations, or videos. thoughts, like understanding Hence, qualitative data artwork, has a creative side. It, however, should follow the steps analysis is not about finding means, frequencies, of qualitative data analysis. statistical differences, or statistical relationships between variables. Qualitative research analysis is understanding and interpretation. about exploration, In qualitative studies the researcher does not have a hypothesis to test. What he has is a phenomenon, which he does not know much about. Thus, the researcher must enter the study with as little pre-set assumptions, as possible about the phenomenon. It suggested that the researcher should be aware of the influence the literature might have on their observations. Unlike quantitative research, there are different qualitative research schools (methodologies). Each of which rely on different interpretation (analysis) technique. [47 ,25], because there are different approaches to interpret human experiences. Each approach (methodology) apply different interpretation method. There are, however, common generic aspects in qualitative data analysis. These represent common analysis techniques. They include “iterative concept”, “coding” and “abstracting”. The iterative approach is an important principle of qualitative research. Iterative method in data analysis means that data analysis starts as soon as data collection begins (from the first 27 interview, or first observation). It is an early repetitive data analysis alongside data collection. This overlapping of data collection represents a dynamic buildup of thoughts, and ideas, which continue to reveal different aspects of the studied phenomenon. The application of this method helps in sample recruitment. As we discover new themes, we recruit participants with relevant experiences to unveil more about these themes. This is called purposive sampling, or theoretical sampling (as in Grounded Theory methodology). The iterative method of analysis also helps in being flexible within the interview/observation to ensure the study uncovers further aspects of data or disconfirming data (contradicting ideas) for emerging themes [49 ,48]. In another word, the researcher can start analyzing the data (uncovering codes and themes) and does not need to wait for the next interview. The researcher starts analyzing the phenomenon under study while listening to the first participant; making sense of the data and writing reflections and thoughts. In this way, as data analysis progresses, the researcher may remove, add, or rephrase the questions to attain a better appreciation of the data. This is another aspect of similarity between painting and qualitative research. During the painting process and as the picture is getting clearer in the artist’s mind, he/ she might change the colors, may add, remove, or change the posture of the figures. Let us have a look at “Napoleon’s Coronation” by JacquesLouis David as an example. I have taken two sketches of one painting’s detail, which is Napoleon’s gesture. If you see the final painting, you may find how Napoleon’s gesture differs from sketches (Figure 5, 6, and 7). 28 Figure (5) Napoleon Coronation by David -sketch Figure (6) Napoleon Coronation, another sketch 29 Figure (7) Napoleon Coronation, a detail from the final painting 30 Coding is essential for qualitative data reporting [48]. It represents the first step in qualitative data analysis. Coding is a way of identifying the basic information units of the data. In another word, the code is a sentence within the speech, or the written text the researcher believes is useful to know. It is not just a matter of labeling, it, rather, helps the researcher to transform raw data into ideas and this is the first step toward data abstraction [47]. Code identification comes through understanding the data. This requires the researcher to immerse himself in the text (data). In another word, repeated listening to the recorded interviews (focus group discussions), and repeated reading of the text. This makes it easy for the researcher to identify the study codes. When the patient says “it was too painful, I couldn’t wait till the morning to seek medical advice”. This could offer a clue for a code. This code can be labeled “pain intolerance”. Similarly, when the patient says: “the dentist smiles a lot and he was so friendly”. This information is a code and can be labeled “dentist approach” Needless to say that the researcher must give attention to every piece of information given in the data. Also, he must not read the data with a preoccupied mind (prejudice way). If they do so, they could lose valuable piece of information. They must remember that doing qualitative research is about exploring without presumptions. For thematic (content analysis) identification of codes and themes is all what is needed (see Thematic Analysis Section). However, in other qualitative schools (methods) coding is the first step in the analysis method. The researcher must move further in data analysis to identify to discover how themes and related codes interact with each other to understand the phenomenon. 31 The next step of analysis is abstracting. It is the main goal of qualitative research. It means moving from preliminary ideas and concepts to (conceptualization). Conceptualization may start with data collection. The term conceptualization refers to reading between the lines. It is a process of exploration and creation. That is why it is considered the most problematic and, at the same time, the most creative part of the qualitative research [47]. Using previously mentioned examples of patient’s responses, we can formulate themes. The patient’s quote in regard to pain can be put under the theme of “concerns before treatment”. These concerns might be “pain intolerance”, “fear of something serious”, and “who is the best dentist I should consult” … etc. The other theme might be put under the label of “management”. This might include: “the dentist approach”, “technical skills”, “dental clinic environment”…etc. In order to use these codes and themes for the next step of analysis we have to organize our data. One of the useful methods of sorting and organizing codes in qualitative health research is the use of the Framework Approach (Table 1) in which data is organized case by case and theme by theme [50] in an excel sheet. This systematic and explicit method to handle the data helps the medical researcher to achieve rigorous analysis and attain trustworthy findings [51]. The last generic element in qualitative research is the Constant Comparative Method (analysis). It is a basic analysis technique used primarily in the Grounded Theory approach and adopted by different qualitative research studies. It is a useful practice in qualitative research to identify patterns that govern the relationship between themes and codes. 32 33 description of the injury case 001 case 002 female 24 female 62 2:16.... I was in so much pain so suddenly it was like my head had just caved in. 2:2 It was a very heavy single impact. I think I said ‘oh dear’ or something like that and felt I didn’t know whether my eye was knocked right out immediate complains/ peroperative complains 23 :2 I was probably disoriented and stuff and I was like I just wanted to lie down on a bed because it made me feel, my face just under just like my cheek bone to the [03:59 ?] was starting to fill with blood and it was bleeding and the pain was so, so immense because I wanted to try and fall asleep or sort of pass out, anything, because I was in so much pain and I knew something was really, really wrong. 8:16 I had some blurred vision … I tended to have blurred vision when I woke up in the morning because a lot of the time it was very sharp, my vision 2:5 and the blood was pouring down my arm. I had my coat on still, so it was pouring down inside my coat. 2:12 I was having difficulty reading the dial on the phone. I don’t quite know why, but maybe there was a lot of water in my other eye. It was all sort of coming and going a bit. Table 1: An example of Framework method for data organization The identified pattern can be depicted as a theoretical construct scheme (Figure 11). This schematic representation shows the pattern that governs the relationship between the study finding (codes and themes). This theoretical construct may be tested and re-tested with more data gathering [52]. Glaser and Strauss, the founders of the Grounded Theory method, divided the constant comparative analysis into four stages: [53] 1. comparison of incidents (codes) within a category (theme) 2. integration of categories and their properties 3. delimiting the theory, which means that the theory solidifies as the modifications of the theory become less with the addition of new data as themes. 4. writing the theory. This comparison continues as more data are collected [23]. Creswell [54] defined another way of explaining data analysis in qualitative research in general. The followings are the steps outlines Creswell’s approach (Figure 8). 1. data organization and preparation: sorting data according to the sources of information. 2. obtaining a general sense of the information provided by the data. Having a general impression of the data includes looking for the general ideas; the general tones within the ideas. 3. coding process, which represents the start of the analytic process. It may be called as an organization of the materials into a block, which is by themselves are organized into categories (themes). These codes and themes are labeled. 4. generating a description, in which codes are used to generate a small number of (7 -5) themes. 5. representing a description of themes, which means 34 Participant’s views A: data organisation B: obtaining general sense of data C: coding D: Theme formation, interpretation Figure (8): A flow chart illustrates qualitative data analysis steps based on Creswell 2003 35 conveying analysis findings using the narrative passage. This could be achieved either by describing the chronology of the event or discussing different themes of relationship. This is usually accompanied by figures or tables as an adjunct to the discussion process. Study themes and their building codes could be outlined in illustrative tables or figures. 6. interpretation, which is the final step of the analysis. It means capturing the essence of the idea. Creswell believes that it is ideal to blend these steps with the specific design of the proposed study [54]. Data analysis might look like a daunting task dealing with textual data of (might reach dozens of pages long). No need, however, to be worried. Like painting, the qualitative data starts to make sense when some cornerstone aspects (interesting ideas) start to appear. In the painting process, the painter starts with an idea, simple might be, then as he put figures and colors on the canvas the idea transforms into the composition. The composition has its elements (figures and colors). 36 Common qualitative methodologies in health studies Qualitative methodology is closely linked to the researcher’s philosophical assumption because the researcher is the research instrument. Keynote: Qualitative data analysis has its schools. Each of which is based on a different assumption, or philosophy. The researcher should state his/her philosophical view to ensure an accurate qualitative study design, [23]. Being a qualitative researcher, as a fine art critic, you need to justify your approach to studying the data/ painting. This is the essence of qualitative methodology. Although qualitative research has a range of approaches based on different beliefs and backgrounds, the generic aim of most qualitative research methods is to develop concepts, explore the meaning of the studied phenomenon, or produces generalizable theory [56 ,55 ,21]. As a fine art fan, you need to ask yourself: What makes you interested in this particular painting, what is it you are looking for? This would be your quest in any research question. There are many paintings in a particular art exhibition or an artist’s webpage. Why this particular theme or particular idea caught your attention? This is the question the art lover needs to answer. Before answering the question, it is essential to know that qualitative research is governed by the phenomenon being investigated [57]. Otherwise, any attempt to legislate the use of any method apart from the research question itself will violate the creativity and viability of scientific research [58]. 37 Thus qualitative research methodology governs the methods within particular research [21]. This, in turn, will influence the nature of the collected data. Similarly, there are many fine art schools and directions, which reflects the difference of views adopted by artists toward their experiences [31]. Accordingly, each fine art example will be used in this guide as an example or a particular qualitative methodology. Giving artistic examples of qualitative data reflect the methodological diversity of qualitative research. There is, however, an important difference between painting interpretation and the methodology of qualitative research. In the qualitative study you can, to some limit, govern the nature of data you work with. This is done by the way you conduct the interview and analyze the data. Being the researcher and the research instrument in a qualitative study is like being the painter as well as the art critic at the same time. 38 Thematic analysis This type of qualitative analysis sheds light on different aspects of the disease process. It can be considered as describing the topographical features (scratches the surface) of the phenomenon. Keynote: Thematic analysis is the most basic approach in qualitative data analysis. It aims to describe the phenomenon without trying to understand the underlying process, or meaning This approach offers a description of a group of participants living an experience at this particular moment in time. It represents, in some ways, what cross-sectional studies represent in quantitative research. It offers an accessible form of analysis, particularly for researchers who are more interested in the descriptive, not the analytical, aspect of qualitative research. This why it is considered as foundational method for qualitative analysis [59]. Thematic analysis is a method for identifying, and reporting data patterns (themes). Identification of themes is the essence of thematic analysis. Themes are the major pattern of the data [60]. As mentioned earlier, the theme is something important about the data concerning the research question and represents some level of patterned response or meaning within the data set. Thematic analysis, as with other qualitative methodologies, begins during data collection. This is performed by moving back and forward between the entire data set. And as mentioned in the data analysis section, these themes themselves are formed by more basic elements termed (codes). The code is the unit of meaningful information related to the phenomenon [59,61] 39 Data analysis in thematic analysis has the following stages; familiarization with the data; generation of the codes; identification of themes; reviewing and naming of themes [62]. A suitable artistic analogy for this approach would be Canaletto’s “Entrance to the Grand Canal” painting (Figure 9). This painting provides a general view of Venice in the 18th century. It is an eyecatching scene from Renaissance Venice. In this painting, the spectators are mainly interested in the diversity of the painting features and how they are richly represented by colorful details. The essence of this painting is more about its components rather than the meaning behind the relationship between those components. The viewer is merely interested in the striking features of the painting itself enjoying the view as it is and not interested in anything else. In the thematic analysis sense, this painting embraces the following themes; the Grand Canal the boats sailing through the canal; the group of buildings on the right side of the view; and the Cathedral at the back of the left side of the view; and the pedestrian at the front of the Cathedral. These are the interesting components of the painting. Identifying these components resembles the identification of themes in the thematic analysis [63]. Each of these painting themes is represented by smaller building blocks (codes); each boat, for example, represents a code within the theme of the sailing boats on the canal. Similarly, each building is a code within the block of the building on the right side of the painting. As the Grand Canal painting, the thematic analysis method provides a general description of the phenomenon (view) enlightening each feature. The researcher in Thematic Analysis does not go beyond the descriptive account of the phenomenon. The research, as the painter, is interested in the view itself. There is no need to move deeper in analysis, as the painting is not entitled to such function. 40 41 Figure (9) Entrance to the Grand Canal, Venice by Canaletto Hypothetical study scenario This is a dental research scenario that assumes the researcher is doing thematic analysis on patient’s views on endodontic treatment. This study can be performed by collecting data from participants who are about to start endodontic treatment; participants who already started their endodontic treatment; participants who finished their treatment; and patients who did not continue with the treatment and decided to extract the affected tooth. From a personal -28year experience in the dental profession, I can suggest a topic guide with the following questions: why did you decide to do the endodontic treatment? How can you describe your experience during the treatment visits? What do you think about the dentist? How did you find the treatment? Topic guide questions can be informed by long practice in the field under study or by the literature about the patients-based outcome. I will assume the following emergent study themes: the fear of endodontic treatment; discomfort and pain during treatment; the dentist approach to the problem; a view on the outcome of the treatment. All the above themes seem plausible from the hypothetical point of view. Each of these themes has a group of codes. For example, the fear of endodontic treatment theme might have the following codes; the fear of the anesthetic needle, the fear of severe pain during treatment, the fear of inability of the dentist to treat the condition properly. The theme of the dentist’s approach might be broken down into the following codes; dentist’s personality, work ethics, professional management to the problem, financial aspects…etc. 42 Grounded Theory Grounded theory was Keynote: developed in the 1960s Grounded theory aims to by the sociologists understand the interaction Anselm Strauss and between different aspects Barney Glaser to study (codes and themes) of the the experience of dying phenomenon to uncover the patients. Ground Theory underlying process that governs (GT) methodology these aspects. It does that addresses the interaction with the deep involvement of between people and how the researcher within the data. do these interactions give meaning to this phenomenon. In technical terms, it is based on the principles of symbolic interactionism [21]. The meaning of Grounded Theory (GT) is discovering a theory, or a theoretical construct, which is grounded in the data. In another word, trying to find what holds different data pieces together. It is like peeling the data layers, layer by layer to reach for the core of the phenomenon under study. Grounded theory is more about the process of interaction between a group of people providing their views on the phenomenon under study over a period of time. It represents, in some aspects, the longitudinal study in quantitative research. (qualitative longitudinal study). In order to understand this interaction, the researcher in GT starts writing reflections, and memos the moment he starts analyzing the data. This is an important element of Constant Comparative Method. He tries to uncover what is between the lines, which holds the story together. He continues to do so with each interview until he achieves his aim. 43 There are two distinct components of GT methodology; theoretical sampling, and rigorous constant comparative methods (CCM) [22]. Theoretical sampling means that data collection continues as the researcher explores new aspects of the phenomenon under study and continues until the theory elements start to formulate within the researcher’s mind. This is different from purposive sampling in other qualitative research methods. Sampling in qualitative research will be discussed in a separate section. In CCM, the chosen segments in each category (code) will be compared with others. This process is progressed by comparing codes and themes (categories). This technique used to find consistencies and differences, for the aim of continually refining concepts and theoretically relevant categories [64]. CCM in the GT approach is usually accompanied by writing memos and reflections during data gathering and analysis [65]. Memos provide a systematic guide for the researcher(s) for the different decisions taken during sampling, coding, theme identification, and building theoretical concepts [64]. In this way, the researcher can formulate a theory or a theoretical construct about the phenomenon under study. The developed theoretical construct reflects the interaction of a group of patient’s views about a particular disease process. It can be about a concept, which drives all the elements to react in a particular way. This is the creative part of this analysis technique. It is often described by data abstraction. Constant Comparative Analysis aims to reach a unifying construct that governs patient’s views toward a particular health issue. To put the participant’s views within the social context, in GT methodology the researcher can use the information provided by the first interviewee in the next interview because he is dealing with a phenomenon in its social context. Here comes the need for theoretical sampling in GT. A participant might unveil an aspect of the studied phenomenon, which might 44 lead the researcher to consider interviewing more participants with similar or related views to complete the picture. There is more than one methodological approach in GT. One of the differences is literature review. Literature review between the schools of Grounded Theory methodology. The traditional Grounded Theory (GT) methodology believes the literature should only be included at the end of the research project, while evolved GT’s believe that literature should be included right from the start [66]. The details of each tradition of GT are out of the context of this book. In this text we will focus on the essential aspects in GT. A suitable fine art analogy to grounded theory methodology is “The Blind Leading the Blind”, a painting by Pieter Bruegel the Elder (Figure 10). The composition of the painting is constituted of painting elements. Each element can be considered as a code. Each tree, or a house, the sky, each individual, the cathedral at the background of the painting, and the hole toward which the blind men are heading. A group of houses may be seen as a theme. A group of trees represents another theme. The same applies to blind men and their leader, which is another theme. The composition of this painting can be comprehended in a better way when we consider the interaction between different painting elements (codes and themes). Unlike thematic analysis, what is important in this painting is not the individual themes and their codes, but the storytelling component, which describes the interaction process between the blind men within the context of the painting environment. This is simply what Grounded Theory Methodology is about. It tries to find the drive behind the dramatic scene of this painting. In grounded theory, there is no separation between elements [31]. All the participants have their role in composing the social phenomenon. 45 46 Figure (10) The Blind Leading the Blind (1568), by Pieter Brugel the Elder Hypothetical study scenario I will use the same endodontic hypothetical study to outline the way the researcher presents the study findings using the GT approach. As mentioned previously, the researcher uses CCM to establish the relations between different codes and themes, moving through the data back and forth, again and again alongside his/ her reflections toward the data. The researchers try to reach the influential element(s) that hold various study codes and themes together throughout the treatment process and beyond (Figure 11). Accordingly, we can hypothesize that confidence in the dentist might influence the patient attitude and decision toward the treatment and the way he/ she deals with discomfort and treatment-related cost. This might seem a reasonable hypothesis. The outcome of GT studies usually expressed in a construct that reflects the process. Fear of Pain and treatment discomfor Dentist approach Positive Level of confidence on Negative attitude the dentist attitude toward toward endodontic endodontic treatment treatment Figure (11) A hypothetical model for the study theoretical construct 47 Generic qualitative research methodology This approach cuts across the most basic aspects shared by different methodological approaches [67]. This means the start with close inspection of a particular dataset to discover certain themes, explore & explain the underlying pattern of the studied concepts and themes [67]. Keynote: Generic qualitative research, like thematic analysis, does not assume any philosophical background. It, however, adopt a methodological approach in some sense close to grounded theory in terms of finding the underlying pattern of the phenomenon. A painting by Shaker Al-Aloosi (Figure 12) might be considered a useful analogy to describe this approach. In this painting, we can see the artist utilizing more than an art school to portray his view, which is a view of local Iraqi women gathered for a tea party. In some sense, it might be considered as a realistic depiction of usual daily practice in an ordinary Iraqi house. In another sense, the artist benefited in some way from cubism as he focuses on the rounded features of the ladie’s faces and legs; and the crescent features of their eyes and the background pillows. with all of this, he exploited the hot colors to create a cozy and seductive feminist environment. To achieve this environment, the painter did not confine himself to a single artistic school. The generic qualitative approach works similarly. It might borrow from more than one qualitative methodological school to answer the research question. In the Generic Qualitative approach, the researcher may utilize the Constant Comparative Method without the need to 48 Figure (12) A painting by Shakir Aloosi 49 provide a theoretical construct to describe a socially interactive process. An example of this adaptation is the theatrical scenes of Delacroix’s “Liberty Leading the People” (Figure 13). Figure (13) Liberty Leading the People by Eugene Delacroix The interaction between painting elements would be more representative here. Each figure in the painting seems to play an integral part in the scene. All their different pauses and gestures are linked to the act of freedom represented by the young lady at the heart of the scene. If we just look at the lady herself, we will not understand the whole idea of painting. The same if we took each figure alone. The spectator cannot unveil the seductive and dangerous meaning of freedom without understanding the interaction between all painting’s elements. 50 Phenomenology Unlike grounded theory or related qualitative research methods, phenomenology is not interested in participant’s interaction within the context of a social phenomenon. Phenomenology tries to understand the unique experience of each person and his/ her particular worldview and to uncover the meaning of this experience. [68 ,21]. Keynote: Phenomenology explores the phenomenon as experienced by each person. It focuses on the meaning and the experience from each individual’s perspective. It does not consider the human experience as part of social interaction process as in grounded theory or generic qualitative methods. In phenomenological studies, the researcher digs deep down to find what is unique about a given phenomenon in terms of experience and meaning to each individual. The phenomenological approach focuses the light on a particular aspect of the experience or its meaning to each individual at the time of investigation (this moment in time). Data collection in phenomenological studies focuses on each individual’s experience. The researcher should not use the information provided by a participant with another participant. This is a major difference between the school of phenomenology and other qualitative research schools. The researcher isolates between individual accounts as he gathers the data [31]. Also, it is not advisable to collect data for phenomenological study using focus group discussion, as group dynamics might influence each opinion. This will violate the individualistic meaning of the given experience [69]. In data collection, as the researcher wants to explore deeper the essence of each aspect of the phenomenon, the 51 researcher uses probe questions more frequently to help the patient elaborate more about each and every particular area of experience. Portrait paintings are examples of individual’s account of a particular phenomenon. As an example of phenomenology “The Girl with Pearl Earring” by Vermeer will be considered (Figure 14). What is the hidden meaning behind this girl’s look and gesture, why this posture in particular, what is specific about the pearl earring, what was Vermeer thinking of? All our questions focus on the real meaning of this masterpiece. These types of questions are similar to the questions related to phenomenological studies. As the researcher interviews patients and analyses the interview data tries to uncover the essence of their experience and what is the real meaning of this experience to them. Figure (14) The Girl with Pearl Earring 52 Self-portrait paintings are the best examples of phenomenological analysis. In a self-portrait, the artist expresses the depth of his feelings and vision. All the composition elements, colors, and brush strokes are about the way he looked at the spectator. It is the essence of this painting. In qualitative research, the researcher may use other identified themes to understand more the aspect under investigation. In this masterpiece, the painting composition, colors, and brushwork reflects the sad, uneasy, and deep look of Rembrandts toward his life, as he gazes toward us. This painting is the essence of life meaning as seen by the artist (Figure 15). Figure (15): Self-portrait, Rembrandt 53 Hypothetical study scenario The same previous case scenario will be used, but the studied phenomenon will be the experience of pain during endodontic therapy. The study, as usual, starts with the usual topic guide. The difference in this study is the researcher’s attempt to explore more deeply the meaning of dental pain and related psychosocial experience throughout the treatment journey. The researcher asks questions about the real meaning of the patient’s description of pain; how did the patient feel when the pain attacks; and how the patient can describe the influence of pain on daily activities? In phenomenological studies, the researcher uses probe questions more often for the sake of reaching the essence of the pain experience; and what is the meaning of pain to them throughout the treatment journey. As the researcher commences with the next interview, he/she should forget all that he knew from the previous interview and avoid asking questions that could be influenced by the knowledge gained from previous interviews. You may ask, how could the researcher consider gathering individual experiences in common codes and universal themes? Using common codes and themes does not violate the phenomenological philosophy, as far as the researcher dealt with each experience at the time of data collection on an individual basis. Data analysis in phenomenological studies provides the researcher’s understanding of different experiences and meanings for a given phenomenon. 54 Interpretive (Hermeneutic) phenomenology Keynote: As a research tradition, interpretive phenomenology tries to separate between the researcher interpretation to the studied phenomenon from the participant interpretation. In qualitative research the researcher is the research instrument. Hence, it is empirical in this research school to avoid mixing between what we think about the experience and what it means for the participant. The difference between the school of phenomenology and the school of Interpretive phenomenology lies behind the fact that phenomenology believes that it is possible to suspend (the researcher) personal opinion. It is possible to arrive at a single, essential and descriptive presentation of a phenomenon [70]. On the other hand, interpretive Phenomenological Analysis refers to the active role of the researcher within the dynamic of the analysis process [17]. This school believes that interpretations are all we have and data description itself is an interpretive process. To generate the best interpretation of a phenomenon means to use the interpretive (hermeneutic) approach [70]. When a fine art critic analyses a portrait painting, does he study the painter’s view of the subject or he allows his view to be part of the process? It is difficult to tell whether he is analyzing the painter’s view of the painting or his view of the painter’s. This is what interpretative phenomenology deals with. Let us take Mona Lisa as an example (Figure 16) What does her smile mean, why did da Vinci put this strange background, what was it he wants us to see, what is the essence of this painting, what is it really about? 55 Figure (16): Mona Lisa, by Leonardo da Vinci 56 Do these questions help us to understand the artist’s view or answer ours? Here we have to consider both sides; the painting side and ours. I chose the Mona Lisa painting because of its richness. It is a clear example of the possibility of different interpretations each spectator can add to its meaning. In interpretive phenomenology, the researcher needs to be aware of his/ her reaction and view of what he is studying to separate between the phenomenon and the way he/she think and react about it [16]. This is often termed as dual interpretation. The first interpretation is the participant’s as he describes his own experience, whereas the second is the researcher’s as he explains the meaning of the participant experience through his interpretation during analysis and writing up [16]. In another word, a detailed Interpretive Phenomenological Analysis (IPA) involves asking critical questions of the texts from participants, such as the following: What is the person trying to achieve here? Is something leaking out here that wasn’t intended? Do I have a sense of something going on here that maybe the participants themselves are less aware of? [17]. Hence, the researcher needs to report his thought, interpretation, or opinion about each given quote by the participants to overcome the overlapping between the researcher and his findings [72 ,71]. 57 Hypothetical study scenario Similar to the phenomenological study scenario, this scenario will consider the pain experience and meaning for patients undergoing endodontic treatment. The difference here will be on the researcher’s interpretation of the participant. It can be hypothesized the patient mentioned the following quote: “The pain was so severe, unbearable, I couldn’t sleep or think or eat. It is horrible. As you see the swelling, it is so painful.” Here comes the researcher’s role in interpreting the patient’s quote: [the patient gave an exaggerated description of the pain experience. He was relaxed and there was no sign of such agony, as described by the patient. I can tell from my experience]. In this way, the reader will feel how the researcher separated his interpretation of the patient’s. Of course, such reflection is useful, as such sensitivity enables the researcher with the tools to explore deeper with the patient’s experience. 58 Writing a qualitative research paper It might be a challenging task for a traditionally oriented dental researcher to write a qualitative research paper. Healthcare professionals used to present and discuss study data using numbers and statistical values. Keynote: Qualitative research paper is a research story. We convince the reader not by numbers, but with participant’s quotes. These quotes are rigorously analyzed and presented within the context of the manuscript. This might explain why some clinical researchers write their qualitative studies in a dry materialistic way. It might be useful to exemplify writing qualitative research as a BBC science documentary. BBC scientific documentaries have both story-engaging elements and are rich in scientific facts. There are, however, different scientific documentaries. Some of these, as mentioned earlier in the book, are useful examples of how to conduct ethnographic studies. In qualitative research, the researchers deal with human experiences, views, thoughts, and opinions about a specific phenomenon. This influences the method of writing. This does not mean writing in a biased compassionate way. It simply means trying to deal with patient’s quotes with respect. For example, it is inappropriate to put participant’s opinions, views, or experiences in tables. Besides, writing qualitative studies requires more eloquent writing skills. In the result’s section of a qualitative study, the researcher uses participant’s/ patient’s quotes, photos, as well as, documents and videos to support their interpretations of patient’s views and opinions. In some instances, it might be advisable for the 59 researcher use to more than a quote from one or more than one participant for each particular finding. Similarly, in fine art articles, the critics support their interpretation of artworks using paintings and sculptures as examples. The researcher needs to be careful with the word choice. The words such as views, and opinions are used in thematic analysis, Generic Qualitative, and GT methods. The words meaning, or lived experience are used in phenomenological studies. It is costumed that patient’s quotes to be written as italic text and it is preferable to refer to the patient at the end of the quote by his/her given code number and gender and age…etc. The researchers should use a consistent language throughout the text that reflects the methodological approach. It is important to adopt concise terms with each methodological approach. In the thematic analysis, per se, it might be better to use the term “explore” in the aim of the study section. In the GT approach, it would be more appropriate to use the term “understand” instead. In the GT method, the researchers need to direct their findings toward a single statement that reflects their theory or hypothesis. In Phenomenological studies, on the other hand, the researchers need to state their aim about the meaning given by the participants toward their lived experience. Human disease is a rich experience. With each health problem, there might be a wide variety of views and experiences. The more we learn about patient’s experience the more we become able to help in both humanitarian and clinical levels. It is the drama and beauty of healthcare, as well as, qualitative research in the medical field. It is very similar to the drama and beauty of human art. 60 References 1. Fossey, E., et al., Understanding and evaluating qualitative research. Aust N Z J Psychiatry, 6)36 .2002): p. 32-717. 2. Grbich, C., Qualitative research in health: An introduction. 1999: Sage Publications Ltd. 3. Morse, J.M., Qualitative nursing research: A contemporary dialogue. 1990: Sage Publications. 4. Speziale, H.S., H.J. Streubert, and D.R. Carpenter, Qualitative research in nursing: Advancing the humanistic imperative. 2011: Lippincott Williams & Wilkins. 5. Camic, P.M., J.E. Rhodes, and L.E. Yardley, Qualitative research in psychology: Expanding perspectives in methodology and design. 2003: American Psychological Association. 6. Willig, C., Introducing qualitative research in psychology. 2013: McGraw-hill education (UK). 7. Alhamdani, F.J.I.J.d.O.H., The importance of qualitative research in dentistry. 2)2 .2016). 8. Pope, C. and N.J.B. Mays, Qualitative research: reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. 6996)311 .1995): p. 45-42. 9. Hartley, S. and M.J.A.p.d.r.j. Muhit, Using qualitative research methods for disability research in majority world countries. 2)14 .2003): p. 114-103. 10. Mays, N. and C.J.B. Pope, Qualitative research: rigour and qualitative research. 6997)311 .1995): p. 112-109. 61 11. Hemingway, P. and N.J.W.i. Brereton, What is a systematic review. 2009: p. 8-1. 12. Burns, P.B., et al., The levels of evidence and their role in evidence-based medicine. 1)128 .2011): p. 305. 13. Geneva, W., Towards a Common Language for Functioning, Disability and Health: ICF. 2002. 14. Alhamdani, F., I. Corbett, and J. Durham, “Is my eyesight gone?” Patient perspectives of orbital blow-out fractures. JODR, 1)3 .2016): p. 19-8. 15. Korstjens, I. and A.J.E.J.o.G.P. Moser, Series: Practical guidance to qualitative research. Part 2: Context, research questions and designs. 1)23 .2017): p. 279-274. 16. Biggerstaff, D. and A.R.J.Q.r.i.p. Thompson, Interpretative phenomenological analysis (IPA): A qualitative methodology of choice in healthcare research. 3)5 .2008): p. 224-214. 17. Eskridge, R., The Enduring Relationship of Science and Art. 2003, The Art Institute in Chicago. 18. Cresswell, J.W., ed. Qualitative Procedures. Research DesignQuantitative, Qualitative and Mixed Methods Approaches, ed. J.W. Cresswell. 2009, Sage Publications: CA. 19. Creswell, J.W. and C. Poth, Qualitative inquiry and research method: Choosing among five approaches. 2007, Thousand Oaks, CA: Sage. 20. Nicholls, D., Qualitative research: Part one – Philosophies. International Journal of Therapy and Rehabilitation, October 2009, Vol 16, No 10)16 .2009 ,10): p. 533-526. 21. Nicholls, D., Qualitative research: Part two-methodologies International Journal of Therapy and Rehabilitation, .2009 11)16): p. 592-586. 62 22. Hancock, B., E. Ockleford, and K. Windridge, An introduction to qualitative research. 2001: Trent focus group. 23. Ghezeljeh, T.N. and A.J.N.R. Emami, Grounded theory: Methodology and philosophical perspective. 1)17 .2009): p. 15. 24. Spencer, L., et al., Quality in qualitative evaluation: a framework for assessing research evidence. 2004. 25. Ormston, R., et al., The foundations of qualitative research. 2 .2014: p. 55-52. 26. Story, T.A., Realism, Concepts and Styles. 2020: https:// www.theartstory.org/movement/realism/history-andconcepts/#concepts_styles_and_trends_header. 27. Berry, D.L., S.L. Maliski, and W.J. Ellis, Qualitative research techniques, in Clinical research methods for surgeons. 2006, Springer. p. 310-297. 28. Hutcheson, F., The Meditations of the Emperor Marcus Aurelius Antoninus. 2012: Liberty Fund. 29. Almeida, F.J.E.J.o.E.S., Strategies to perform a mixed methods study. 2018. 30. Proudfoot, K.J.J.o.M.M.R., Inductive/Deductive Hybrid Thematic Analysis in Mixed Methods Research. 2022: p. 15586898221126816. 31. Nicholls, D., Qualitative research: Part three–methods. 12)16 .2009): p. 647-638. 32. Pope, C., S. Ziebland, and N. Mays, Qualitative research in health care. Analysing qualitative data. BMJ, .2000 7227)320): p. 6-114. 33. Hancock, B., W. K., and O. E., An Introduction to Qualitative Research. 2007, The NIHR RDS EM: YH,. 63 34. Powell, R.A. and H.M.J.I.j.f.q.i.h.c. Single, Focus groups. 5)8 .1996): p. 504-499. 35. Wong, L.P.J.S.M.J., Focus group discussion: a tool for health and medical research. 3)49 .2008): p. 60-256. 36. Kitzinger, J.J.S.o.h. and illness, The methodology of focus groups: the importance of interaction between research participants. 1)16 .1994): p. 121-103. 37. Britten, N.J.B., Qualitative research: qualitative interviews in medical research. 6999)311 .1995): p. 253-251. 38. Arthur, S., J.J.Q.r.p.A.g.f.s.s.s. Nazroo, and researchers, Designing fieldwork strategies and materials. 1 .2003: p. 137-109. 39. Arthur, S. and J. Nazroo, eds. Designing Fieldwork Strategies and Materials. QUALITATIVE RESEARCH PRACTICE A Guide for Social Science Students and Researchers, ed. J.A.N.E.R.I.T.C.H.I. E and J.A.N.E.L.E.W.I. S. 2003, Sage Publications: London. 40. Kvale, S.J.Q.i., Dominance through interviews and dialogues. 3)12 .2006): p. 500-480. 41. Murphy, E., et al., Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment 16)2 .1998): p. 275-1. 42. Alhamdani, F. and A.T. Jiboon, Postgraduate Maxillofacial Training from Student’s Perspective. Azerbaijan Medical Journal, 8)62 .2022). 43. Faaiz Alhamdani, B., Dental Student’s Views of Their Clinical Cognitive Skills. A Qualitative study. 2017. 44. Legard, R., J. Keegan, and K. Ward, eds. In-depth Interviews. QUALITATIVE RESEARCH PRACTICE A Guide for Social Science Students and Researchers, ed. J.A.N.E.R.I.T.C.H.I. E and J.A.N.E.L.E.W.I. S. 2003, SAGE Publications: London. 64 45. Legard, R., et al., In-depth interviews. 1)6 .2003): p. 169-138. 46. Lempp, H. and G. Kingsley, Qualitative assessments. Best Practice & Research in Clinical Rheumatology, 5)21 .2007): p. 69-857. 47. Richards, L. and J.J.R.f.f.a.u.s.g.t.q.m. Morse, The integrity of qualitative research. 2007: p. 44-25. 48. Endacott, R.J.I. and C.C. Nursing, Clinical research 4: qualitative data collection and analysis. 2)21 .2005): p. 127-123. 49. Pope, C., S. Ziebland, and N.J.B.B.M.J. Mays, Qualitative research in health care: Analysing qualitative data. .2000 7227)320): p. 114. 50. Furber, C.J.A.J.o.M. and W.s. health, Framework analysis: a method for analysing qualitative data. 2)4 .2010): p. 100-97. 51. Smith, J. and J.J.N.r. Firth, Qualitative data analysis: the framework approach. 2)18 .2011): p. 62-52. 52. Strauss, A. and J. Corbin, Basics of qualitative research. 1990: Sage publications. 53. Glaser, B.G. and A.L.J.A.B.S. Strauss, Discovery of substantive theory: A basic strategy underlying qualitative research. 6)8 .1965): p. 12-5. 54. Creswell, J.W. and J.D. Creswell, Research design: Qualitative, quantitative, and mixed methods approaches. 2017: Sage publications. 55. Ritchie, J., et al., Qualitative research practice: A guide for social science students and researchers. 2013: sage. 56. Pope, C., N. Mays, and J. Popay, Synthesising qualitative and quantitative health evidence: A guide to methods: A guide to methods. 2007: McGraw-Hill Education (UK). 65 57. McEvoy, P. and D.J.J.o.r.i.n. Richards, A critical realist rationale for using a combination of quantitative and qualitative methods. 1)11 .2006): p. 78-66. 58. Colliver, J. and S.J.A.M. Verhulst, Medical research and qualitative methods: a rational approach. 3)71 .1996): p. 211. 59. Braun, V. and V.J.Q.r.i.p. Clarke, Using thematic analysis in psychology. 2)3 .2006): p. 101-77. 60. Ryan, G.W. and H.R.J.H.o.Q.R.n.e.T.O. Bernard, CA: Sage Publications, Techniques to identify themes in qualitative data. 2000. 61. Boyatzis, R.E., Thematic analysis and code development: Transforming qualitative information. 1998. 62. Nowell, L.S., et al., Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods, 16 .2017: p. 13-1. 63. Braun, V. and V. Clarke, Using thematic analysis in psychology. Qualitative Research in Psychology, 2)3 .2006): p. 101-77. 64. Chun Tie, Y., M. Birks, and K.J.S.o.m. Francis, Grounded theory research: A design framework for novice researchers. 7 .2019: p. 2050312118822927. 65. Creswell, J.W., et al., Qualitative research designs: Selection and implementation. 2)35 .2007): p. 264-236. 66. van Rensburg, A.J. and W.I.J.M.j.o.s.s. Ukpere, Application of grounded theory in career research reviewed. 4)5 .2014): p. 543-543. 67. Rapley, T. and D. Silverman, Qualitative research: theory, method and practice. 2010. 68. Langdridge, D., Phenomenological psychology: Theory, 66 research and method. 2007: Pearson education. 69. Guzys, D., et al., Gadamerian philosophical hermeneutics as a useful methodological framework for the Delphi technique. 1)10 .2015): p. 26291. 70. Kafle, N.P.J.B.A.i.j., Hermeneutic phenomenological research method simplified. 1)5 .2011): p. 200-181. 71. Snape, D., L.J.E.b.J.R. Spencer, and J. Lewis, Qualitative research practice: A guide for social science students and researchers. 2003. 72. Snape, D. and L. Spencer, eds. The Foundations of Qualitative Research. QUALITATIVE RESEARCH PRACTICE A Guide for Social Science Students and Researchers, ed. J.A.N.E.R.I.T.C.H.I. E and J.A.N.E.L.E.W.I. S. 2003, SAGE Publications: London. 67