Beyond theming: Making qualitative studies matter

As qualitative research methods become increasingly popularized in nursing and other applied disciplines concerned with the intricacies of the human condition, it is important to think carefully about why we do qualitative work and how we ought to judge whether the reports of such work constitute a meaningful contribution to the literature. Here are a few thoughts from the perspective of a journal editor who reads many such manuscripts and has an investment in the quality of qualitatively derived knowledge. Although methods for qualitative inquiry in the health sciences were initially borrowed from their social science origins, they are increasingly being adapted into various ‘applied’ approaches that better suit the distinctive knowledge needs of the practice disciplines. It is not that we are averse to theorizing, but that is rarely the primary intended outcomes of our forays into qualitatively examining a phenomenon. For the most part, until you have done some exploratory qualitative work on topic in question, it is somewhat difficult to judge whether new theorizing about it is or is not going to be needed to advance our thinking. More often, our objectives in qualitative inquiry are to fill in gaps that quantitative studies have left exposed, to insert patient perspectives into our more objective clinical understandings, or to consider whether there may be meaningful similarities and differences among people with respect to the way they experience common circumstances or situations. These are questions that have arisen from our deep knowledge of the clinical practice context and our curiosities with respect to those aspects that seem as yet incomplete or puzzling. Applied methods focus our attention on finding satisfying ways to begin to answer those kinds of questions, rather than to achieve more abstract theoretical heights (Thorne, Stephens, & Truant, 2016). As more and more scholars are seeking qualitative methodological options short of the full-blown theorizing that was anticipated in the design rules for many of the social science approaches, we are also seeing an increasing array of somewhat ‘dumbed down’ options for data analysis. The worst of these, from the perspective of this journal editor, is the emphasis on ‘theme’ identification as a legitimate endpoint of analysis. ‘Finding themes’ is a way to describe one part of an inductive analytic process, but just the part that has to do with surface-level considerations. It taps the part of our brain that notices commonalities among things, aspects that are similar from one case to another. And as a beginning point of analysis, it may help us get a grip on organizing our thinking about what is there to be discovered. But, it does not serve us well as a place where analysis ends. A genuine clinical curiosity must lead to a more complex line of intrigue in which we ask ourselves why we have noticed these patterns or similarities and what they might mean. Often, by taking note of what comes first to mind, we are reminded of the biases we may have brought into our studies—those assumptions we may have had as to what was there to be found. And having found similarities, we then have an obligation to purposively orient our thinking to diversities—what have I not noticed because I have first attended to that which seems common? Further, because we do our applied work in fields in which we have a wider contextual frame than simply that which has landed in our data set, we have fodder for additional critical reflection on what we have and have not got before us. What of the wider clinical world I recognize has not found its way into my study? And does that matter? What would it reflect for my clinical community if I assumed my data set was a reasonable representative of the whole? The problem with superficial data analytic processes is that they give the impression that stopping at naming key themes is sufficient and worthy of reporting or publishing. For many of us in nursing, the idea of ‘thematic analysis’ first appeared in Corbin and Strauss's rendering of the original Glaser and Strauss (1967) Discovery of Grounded Theory methodology. As later popularized by Corbin and Strauss (2014) (the original by Strauss & Corbin in 1990, now in its 4th edition), and then Braun and Clarke (2006, 2014), thematic analysis represented the first few steps in what was envisioned as a much longer and more complex analytic path. And because the mechanism of data management that methodology espoused was coding—often many layers of coding (Saldaña, 2009)—we became accustomed to the idea that scholars would talk about their data in terms of ‘categories’ and ‘themes’. Although some authors make no distinction between the two—they are merely different labels for organizational groupings—others do make a conceptual distinction. For example, Morse describes categories as collections of similar data sorted into the same place, and themes as a more meaningful ‘essence’ that runs through the data. She describes a theme as ‘the basic topic that the narrative is about, overall’ (2008, p. 727). But as Sandelowski wrote in her classic paper entitled Words that Should be Seen but not Written, these are terms ‘that refer to the work of analysis, and not to any dimension of the findings, are used to present the findings and thereby ironically obscure them’ (2007, p. 129). Although the original methodological authors had clearly intended thematic analysis to be a robust form of applied research, we can see from a quick survey of the published literature nowadays that all too often it is not. In some instances, this problem is further exacerbated by the addition of what is known as ‘qualitative content analysis’, popularized by Hsieh and Shannon (2005), and essentially meaning that the themes being reported were not in fact inductively derived from a rigorous analytic process, but rather came into the study from the outset in the form of a theoretical framework. At this level, the work becomes simply an organizational maneuver, fitting data bits into theme categories that have been predetermined before the start. In such cases, the written reports of the findings almost never reflect anything new or interesting as they derive from data management procedures rather than intellectual effort. Why would nurses have fallen into this trap of allowing for a form of qualitative scholarship that does not really add much to the field? It seems to me that they may have extrapolated the relevance of this from the ‘pattern’ identification that is so familiar to us from Benner's classic work on From Novice to Expert (1984). In that work, Benner was helping us understand that expert thinking in nursing practice was not merely a matter of incremental learning of new facts, but rather an expanding capacity to interpret variations and anticipate their implications by virtue of having critically reflected on an extended set of complex case exemplars over the course of many years. We came to refer to this phenomenon as ‘pattern recognition’, and for many nurses, it became a means by which to think about how clinical wisdom accrues over time—including why different nurses with equal time in the practice field and exposure to cases will not necessarily end up with the same demonstrable level of clinical expertise. Further, we understand this clinical wisdom as an integral element of evidence-based practice. Not only do you need the evidence itself, but also the clinical wisdom and patient preference understanding in order to render a high-quality clinical decision informed by it. So in this context, thematic analysis may have become conflated with pattern recognition, such that the reporting of patterns within a data set may have seemed in and of itself to be a relevant exercise. However, qualitative research is meant to add value to a field rather than simply reporting what we can detect about it that has the qualities of a pattern. We ought to be aiming for a convincing account of a clinical topic beyond what would be self-evident to the reasonably astute practitioner or anyone with a reading knowledge of the published scholarly work on the phenomenon in question. Qualitative work is meant to add insight—to take us somewhere beyond what we already know. Thus, for a qualitative product to be worthy of publication, I believe that it must demonstrate that it extends beyond naming categories and themes and reporting on patterns. In order to be publishable, it should clearly add to our body of understanding in some meaningful manner. Telling your reader that you found three themes and fourteen categories and then going on to briefly describe them and provide a text excerpt example of each is hopelessly insufficient. Your challenge is to show us that there was some purpose in your having done so and to guide us into the new level of understanding that can be arrived at on the basis of an auditable explanation of the forays you have made into these different options for compartmentalizing, sorting, and interpreting data. In an ideal world, thematic analysis would never be considered a qualitative data analysis method on its own any more than data sorting or filing would be. Rather, it will be but one aspect of a complex, and intellectually difficult, and yet absolutely exhilarating process of genuine discovery—in-depth interrogation of the data, critical reflection on its interrelationships, thoughtful examination of possible interpretations, and, finally, insightful and elegant reporting.