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Use the information below to help you know which section of the article to use to answer questions in the template:Introduction and its subsections have the purpose or WHY the study was done.Methods section and its subsections contain HOW the study was done.Results, Discussion, and Conclusions section will have WHAT was found. Each section of the template is required to be completed as this assignment builds on your Evidence-Based Practice Project. Each template has a citation that must be submitted in APA format. Answers to questions in Synopsis sections are required (see template examples in your book). Each question must have an answer of 1-2 full sentences in length per question. Credibility section Yes/No answers are also required. The Comments area is also required and should be at least 1-3 sentences noting how this article relates to your nursing issue topic from week 3 and what you thought was significant.My topic has been on Venous Thromboembolism attached below is the documents which need to be filled out and the pdf articles which are to be used
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Res Pract Thromb Haemost. 2021 Aug; 5(6): e12593.
PMCID: PMC8435525
Published online 2021 Sep 12. doi: 10.1002/rth2.12593
PMID: 34532630
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The use of qualitative methods in venous thromboembolism research
Similar articles
Jackeline Hernandez‐Nino, MD, 1 Mary Thomas, MD, MPH, 2 Andreia B. Alexander, MD, PhD, MPH, 1 Mary A. Ott,
MD, MA, 3 and Jeffrey A. Kline, MD 1
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Abstract
Go to: ▸
Introduction
Qualitative research has been increasingly used in health care research to allow in‐depth insights and
understanding of patients’ lived experiences for poorly understood phenomena. The psychological stress
mechanisms underlying fear, dyspnea, and pain after venous thromboembolism (VTE) remain poorly
understood. However, novice VTE researchers may not be familiar with the process of undertaking
qualitative research.
Objective
The aim of this article is to describe the planning, methodology and execution of qualitative methods,
using the example of patients’ lived experiences during and after the diagnosis of VTE. We discuss
challenges and solutions in implementing qualitative research methods in health care research.
Methods
Patients were recruited from the emergency department and clinic using in‐person and phone contact. We
used both in‐person and video format to interview 24 patients. Interviews were guided by a set of
questions to be explored but conducted to elucidate unique thoughts and opinions from patients.
Results
For recruitment, “cold‐calling” was found to be largely unsuccessful. Many patients have preexisting
diagnoses of anxiety and depression. Video interviews were found to be at least as effective as in‐person
interviews. Interviews revealed unique post‐VTE experiences from all participants, with a wide range of
impact on quality of life. Themes that were most common included perceptions of physician
communication, fear of recurrence, and concerns of death.
Conclusion
A qualitative research approach can reveal individual experiences and psychosocial impact in patients
diagnosed with VTE, which allow the researchers to better comprehend the complexity of this
phenomenon and its impact in health care.
Keywords: challenges, methods, psychological stress, qualitative research, solutions, venous
thromboembolism
Essentials
Health care researchers may not be familiar with starting a qualitative study.
Qualitative research was used to explore lived experiences in patients with blood clots.
This provides a detailed account of the planning and execution of a qualitative project.
Challenges and solutions are described to guide new researchers.
1. INTRODUCTION
Go to: ▸
Despite the increasing acceptance of qualitative methods in health care research, qualitative methods have
been slow to impact research and medical practice related to venous thromboembolism (VTE).
Qualitative research, through detailed descriptions and open‐ended approaches, offers a different
approach to identify what is important for patients and to improve health care experiences. It allows
researchers to reach areas that cannot be measured by quantitative research.1 For patients with VTE,
overutilization of emergency departments (EDs) is an example of a significant health care problem with
high financial and human costs that could benefit from qualitative approaches.2
Qualitative research involves collecting and analyzing nonnumerical data to understand human
experiences, conveyed by the expression of opinions, behaviors, concepts, beliefs, attitudes, and
interactions with other humans.3 Qualitative methods allow access to in‐depth insights and understanding
of real‐world problems from the patient perspective and are particularly helpful when little is known
about a topic, when quantitative results are unexpected, or when a problem, like overuse of EDs, proves
to be persistent and recalcitrant to interventions. Qualitative methods do not require an a priori
hypothesis, or preidentification of variables, making them ideal when a health services topic is poorly
understood.4 Qualitative methods are an important tool for health care, as they can identify the impact of
social determinants such as sex, education, poverty, race, or religion on the conduct and outcomes of
research.5, 6
Over the past decade, there has been increasing attention to the quality and rigor of qualitative studies in
health research generally, including methodological guidelines for qualitative health research. Checklists
have been published to improve the reporting of research methods, coding, analysis, and results, as well
as the interpretation of qualitative work, which allow a structured and reproducible critique of qualitative
research (checklist for the current manuscript is provided in supplemental information).7 Missing,
however, from existing methods literature are detailed examples of how qualitative research methods can
be applied and discussions of challenges, solutions, and adaptations.
Using the case of venous thromboembolism (VTE) research, we describe a qualitative approach to
understand patients’ lived experiences of VTE. The purpose of this article is to describe the application
of qualitative methods, as well as challenges and solutions, in implementing qualitative research on health
care topics. We first provide a detailed account of the planning and execution of a qualitative project and,
second, describe challenges and solutions for future researchers selecting qualitative methods.
2. DISEASE MODEL: VTE
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The target condition for this work is VTE, defined as deep vein thrombosis (DVT), pulmonary embolism
(PE), or both. VTE affects >600,000 individuals in the United States each year, causing considerable
morbidity and mortality.8, 9 About 5% to 15% of patients with VTE have a recurrence in the first year if
anticoagulation therapy is discontinued after 3 to 6 months.10 By 10 years, approximately 40% of patients
with unprovoked VTE will have experienced a recurrence, increasing risks for complications and
mortality.
In addition to the risk of recurrence, ≈30% of PE survivors develop substantial ongoing reductions in
mental and physical health that greatly impair their quality of life.11, 12, 13, 14 If DVT is included, the
number affected at least doubles, in part because of the impact of the postthrombotic syndrome, a chronic
consequence of DVT characterized by leg swelling, pain, edema, venous ectasia, and skin induration.15
Persistent symptoms likely amplify fears of recurrence,16, 17 and these fears, coupled with concerns about
side effects of anticoagulants used to treat the condition, contribute to a lifelong cognitive and health
burden. It is thought that persistent symptoms and fears may play a causative role in frequent ED visits.
These visits can result in unnecessary testing that requires ionizing radiation, are costly (both financially
and personally), and do not change plans of care. This low‐value use of the ED contributes to the high
long‐term economic burden of VTE.18, 19
Accordingly, this qualitative study was undertaken with the belief that qualitative methods can provide an
opportunity for a better in‐depth understanding of how and why the diagnosis of VTE may impact
individuals and their use of the health care system.
3. QUALITATIVE RESEARCH DESIGN
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A qualitative method, in‐depth individual interviews, was selected to allow for richly detailed data about
the lived experiences of patients diagnosed with VTE and the psychosocial impact of VTE on patients.
This approach was selected because there is little known about patients’ lived long‐term experience of
VTE, and in‐depth individual interviews (similar to other qualitative approaches) allowed our team to
generate an explanation of a process of health care usage shaped by the views of a number of participants
on this particular phenomenon.20 For patients with VTE, limited prior research has described their goals,
fears, expectations, values, concerns and anxiety.17, 21, 22, 23 This qualitative analysis allows us to describe
the lived reality that consists of people’s individual experiences and how individuals interpret those
experiences. Using textual data from interviews, the aim of this research was to generate explanations and
theories on how individuals with VTE use health services.
We chose to use additional quantitative measures to more accurately describe participants’ severity of
VTE and comorbid conditions, such as anxiety, posttraumatic stress disorder, and postthrombotic
syndrome, and quality of life after VTE. Quantitative self‐administered surveys were administered
immediately after the interview. The addition of quantitative measures to this primarily qualitative study
allowed us to compare patients’ experiences with more objective measures of disease severity and
comorbidities.
4. SAMPLING AND RECRUITMENT METHODS
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Purposive sampling was used to identify participants. Purposive sampling is a nonprobability sampling
approach in which informants are selected to capture a range of experiences and characteristics.4 Ideally,
informants will be willing to share their experiences and have good communication skills and the ability
to reflect upon their experiences. For this study, we sought a range of ages, varied types and severity of
VTE (PE only, PE and DVT, or DVT only). We also sought participants who had a wide variety of health
care experiences, including those who were discharged home from the ED or had more intensive
treatment (eg, reperfusion therapy), and those representing a wide range of VTE recurrences, time since
diagnosis, and ED visits. See Table 1 for participant information.
TABLE 1
Clinical characteristics of participants
Female (n = 15) (%) Male (n = 9) (%) Total (n = 24) (%)
Age, y
50
9 (37.5)
5 (21)
14 (58.5)
Black
6 (25)
2 (8.5)
8 (33.5)
White
9 (37.5)
7 (29)
16 (66.5)
Married
6 (25)
6 (25)
12 (50)
Single
3 (12.5)
1 (4)
4 (16.5)
Divorced
3 (12.5)
1 (4)
4 (16.5)
In relationship/not married 3 (12.5)
1 (4)
4 (16.5)
Race
Marital status
Time since VTE diagnosis, y
2
11 (46)
4 (16.5)
15 (62.5)
2 (8.5)
3 (12.5)
5 (21)
Received thrombolysis
Yes
Cited by other articles
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Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism.
To capture a range of patient experiences, in particular recurrence and ED usage, we used several
different recruitment approaches. We first used databases from a university hospital anticoagulation clinic
(>50% patients with DVT only), a registry kept of patients treated with multidisciplinary pulmonary
response team, as well as patients who participated in other VTE research studies by our group. We also
used the electronic medical record (First Net; Cerner Corp., North Kansas City, MO, USA) to survey
patients presenting to the IU Health Methodist and Eskenazi Hospital ED in Indianapolis to identify
potential participants who were diagnosed with VTE at least 6 months prior. Participants were between
the ages of 18 and 70 years who had experienced a symptomatic VTE as a DVT, PE, or both at least 6
months prior to the interview. Participants were excluded if they had a diagnosis of active cancer or
known history of mental illness or other psychological diagnosis before the VTE with the exception of a
diagnosis of anxiety or depression. This study was approved by a local institutional review board (IRB).
This study was conducted in compliance with the ethical standards of the responsible institution on
human subjects as well with the Helsinki Declaration.
The main challenge for the sampling and recruitment was the time and effort required to screen and enroll
participants. To complete the 24 interviews, the first author (JHN) reviewed 620 charts from the different
VTE study databases for inclusion, exclusion, and sampling criteria. The time required for this screening
process ranged from a few minutes (eg, when age was found to be an exclusion criterion) to 90 minutes
(when the participants had a contradictory past medical history or unclear psychiatric history). To
expedite this process, the participants with contradictory or unclear medical history were flagged to do a
more detailed assessment of the exclusion criteria during the phone call. Ultimately, 160 participants met
the criteria. After the participant met the inclusion criteria, the study personnel or the principal
investigator (PI) then initiated phone calls to inquire about interest in participating. The time spent on
phone calls varied from 1 minute (when calls were not answered, or the number was not in service) to
30 minutes (to explain the study to the participant and schedule the interview).
The second challenge was the original exclusion criterion of history of mental illness. The diagnosis of
anxiety and depression excluded the majority of otherwise eligible patients. Simultaneously,
documentation of mental health disorders was inconsistent and often incomplete, requiring PI
investigation of unexplained International Classification of Diseases codes in the absence of a
documented formal psychiatric or even primary care mental health evaluation.24 As a solution, we
changed our original exclusion criteria of history of mental illness to known history of mental illness or
other psychological diagnosis prior to VTE diagnosis with the exception a diagnosis of anxiety or
depression. This change in the exclusion criteria increased the number of participants eligible to be
called; however, these protocol changes only modestly helped the rate of recruitment because of
pervasive problems with telephonic recruitment.
We were able to obtain a waiver from the IRB for recruitment but found that the “cold‐call” telephone
contact method proved to be highly inefficient.25 Approximately 14% of telephone numbers had
disconnected service. An additional 51% of participants were unable to be reached. In 75% of these cases,
the caller left at least one voice message and never received a call back. Nineteen percent answered the
first phone call and asked to be called another time but did not answer the subsequent call. Fifteen percent
refused to participate in the study. The remaining 6% of calls were never answered or the voicemail was
full.
Additional opportunity cost resulted from 27% of scheduled interviews who failed to show, with only two
of those participants completing the interview after rescheduling. In an attempt to improve outcomes,
every participant was called at least three times on different days, at different times. A minimum of three
calls were made to numbers not obviously disconnected with an average of six to seven calls per patient.
Despite strenuous effort and protocol modifications, the recruitment effort required 9 months to complete
interviews with the first 15 participants. After the coronavirus disease 2019 (COVID‐19) pandemic
began, and state and local stay‐at‐home public health orders began, the number of participants who
answered the phone calls increased, and within 2 months, 13 individuals agreed to participate. Because of
the convenience of virtual interviews, we were able to retain a higher proportion of participants, and nine
completed interviews. However, two participants were unable to complete the interview due to lack of
access to computer, smartphone or internet, and two participants did not answer the day of the interview.
One of them was reached later again but declined to complete the interview due to being admitted to the
hospital, and the second participant never answered the calls to be rescheduled.
5. SAMPLE SIZE
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Qualitative sample size is determined by thematic saturation rather than mathematical calculation.
Thematic saturation is the point at which the interviewer has uncovered the full range of perspectives in
the population interviewed, and subsequent interviews no longer uncover new ideas. It is dependent upon
a variety of factors, including the purposive sampling approach and the diversity of perspectives in the
purposive sample. We had originally planned on 30 interviews. However, with a total of 24 interviews,
we felt that we achieved thematic data saturation, based on repetition of statements and themes.
6. STUDY PROCEDURES
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The initial design of the study was to interview all participants face to face to facilitate the development
of rapport between the interviewer and interviewee, reduce distractions, and allow the interviewer to read
the participant’s body language.
However, to adapt to the public health orders related to COVID‐19, interviews were switched to a web
conferencing platform (Zoom; Zoom Video Communications, San Jose, CA, USA) after the first 15
interviews. We adapted the same structure, identical format, and verbal instructions for COVID‐19–
adapted video interviews and tracked the duration and content of these video interviews to compare to
face‐to‐face interviews. The duration of the interview remained identical after the transition from face‐to‐
face interviews to a web conferencing platform (Zoom). Overall, the web conferencing offered logistical
advantages. The access to geographically remote participants, the reduction on travel expenses for
participants and interviewer, and savings on setup cost were key advantages.
Nonetheless, we identified a few challenges with the web conferencing platform. Two participants were
unable to be enrolled because they did not have access to the necessary technology
(Internet/smartphone/computer). The ability to establish a natural, relaxed conversation and observe body
language was significantly reduced with two participants who used a cellphone for the video call. This
was largely because the participants were holding the cell phone in their hands throughout the interview,
which focused the camera only on their face and took away the ability to observe nonverbal cues. Finally,
one participant who had never participated in a videoconference seemed distracted by the process. This
was evidenced by the participant’s inability to focus on the verbal conversation and requiring frequent
redirection throughout the interview. The participant seemed fixated on the video display, often fixing the
hair and asking whether the interviewer could see and hear well.
For the face‐to‐face interviews, participants were interviewed individually in a quiet and private office
with no others present, not bright lights and neutral background to avoid distractions. A “Do Not Disturb
—Interview in Process” sign was placed outside the door to minimize interruptions. When the interview
was done by a web conferencing platform, the interviewer used the same place and the participants were
asked to be in a location that would ensure privacy and prevent interruptions.
Two audio recorders were used during each interview to ensure that the interview was recorded
completely and accurately and to allow the PI to focus during the interview. None of the interviews
required a repeat session. All interviews were transcribed verbatim by a professional transcriptionist.
None of the transcripts were returned to the participants.
Most interviews lasted 75 minutes and were followed by completion of five questionnaires: Generalized
Anxiety Disorder Scale, Posttraumatic Stress Disorder Checklist, Pulmonary Embolism Quality of Life
questionnaire, Villalta Scale for Diagnosing Post‐Thrombotic Syndrome, and the Concerns About
Recurrence Scale—VTE.
7. INTERVIEWER CHARACTERISTICS
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In qualitative work, we found it important to be attentive to the interviewer characteristics as well as the
interviewer‐interviewee relationships. In this study, the interviewer had no prior clinical relationship with
any of the 24 participants. We felt that it was important for the interviewer to not be the patient’s medical
provider because we wanted patients to be free to express negative as well as positive experiences with
the health care system and to not feel pressured to participate. However, we did feel that it was important
for the interviewer to have prior knowledge on the topic (in this case VTE) and research expertise. The
interviewer was a female internal medicine physician, has both clinical care and research experience with
VTE, as well as both clinical and qualitative interview experience.
8. INTERVIEW GUIDE DEVELOPMENT
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Interview guides for qualitative research range from completely unstructured to highly structured. We
opted to use a semistructured approach, in which all participants were asked the same main questions, but
the interviewer followed up with different probing questions, depending on the answer to the main
question. The use of a semistructured approach enabled us to cover all pertinent areas but also allowed
participants to bring up topics we had not previously considered and to provide a high degree of detail.
Our preliminary interview guide was developed on the basis of pertinent information gathered from a
review of the literature.16, 22, 23 Then, the interviewer conducted three pilot interviews to test the guide.
These pilot interviews allowed us to refine existing questions. Questions that did not work well were
dropped, and questions were added on the basis of participant feedback. We set up our questions to
encourage participants to tell their story. In contrast to questions that allow short or single‐word answers,
a storytelling approach allowed a more detailed narrative. The use of a semistructured guide enabled
flexibility to ask questions that incorporated new information and to follow new ideas as they came up in
the interview.
9. INTERVIEW PROCESS
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While the goal of the qualitative interview is to feel like a conversation, the emphasis is on active
listening. At the beginning of the interviews, the roles were clarified: The participant was counseled that
the interviewer would ask questions but mostly listen and the interviewee should do the majority of the
talking. The interviewer stated that the interview was intended to be conversational with no expectation
of right or wrong answers.
The interview structure started with asking the participants to describe the time when they were
diagnosed with VTE. We deliberately asked the interviewee to tell us their “story” of VTE both to serve
as a warm‐up for the interviewee because of its ease and allow for often unexpected details that come
from storytelling. Probing questions were used to elicit details of the story.
The interviewer then inquired about the participant’s knowledge of VTE to compare his or her knowledge
at the time of the diagnosis with his or her current knowledge. As the interview progressed, the
interviewer posed more challenging questions involving life‐changing aspects due to the diagnosis,
concerns and fears about the diagnosis, and coping mechanisms and emotional support, which also
presented challenges to the interviewer.
A strength and a challenge in qualitative interviewing is the ability of the interviewer to identify and
explore discrepancies in the participant’s stories. For example, when participants were asked about
mental health after VTE diagnosis, most participants denied having any anxiety, worry, or concern after
the diagnosis; however, the same participants described signs of anxiety, fears, concerns, and worries
after the diagnosis throughout the interview. In these situations, the interviewer would ask the same
question using more neutral words, avoiding words clearly aligned with mental health, such as anxiety,
worry, depression, or stress, in attempt to overcome their reluctance to endorse anxiety or worry about the
disease. For example, the interviewer might ask: “What comes to your mind?; or “What do you think
when you start having shortness of breath or chest pain or leg pain?”; or “Tell me about changes in your
life after the blood clots.” This discrepancy was more prevalent with male participants, and we
hypothesized that this might be related to the perceived stigma of a mental health diagnosis.
A second challenge in qualitative interviews on health services is that often informants do not know basic
knowledge about their own health care condition. This raises both practical and ethical concerns. In a
successful qualitative interview, the interviewer and interviewee build a relationship of trust, and when
there is that level of trust, interviewees are often more willing to make themselves vulnerable and
disclose lack of knowledge or ask for assistance in understanding their conditions when they would not
have otherwise. In our study, a subset of participants had questions about their disease or treatment during
the interview. While the goal of qualitative interviews is for the participant to express their feelings,
perceptions, and decisions based on their current knowledge, a competing obligation is to resolve
misinformation that may negatively affect a person’s health. In our study, the interviewer addressed these
questions when all research procedures (interview and questionnaires) were completed to prevent the
answer from influencing the participant’s opinions/beliefs during the interview. For example, the
interviewer might say, “I am going to table your question for now, but we will come back to it at the end
of the interview—is that OK with you?”.
All interviews ended with the interviewer asking if the participants had any experiences or information
related to VTE to share that had not been asked. This was done to make sure the participants had the
opportunity to share anything that may have been missed in the interview but also to reiterate the value of
their opinion. The majority of participants felt everything they wanted to discuss was covered in the
interview.
10. CODING AND ANALYSIS
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All the transcripts were reviewed by the investigator for accuracy and completeness and then uploaded
into NVivo software (QSR International, Melbourne, Australia). NVivo allowed for an organized and
structured approach to the coding process as it facilitated categorization and comparison of the codes for
data analysis.
Using two or more independent coders, or “double coding,” is one way to improve validity. Some more
structured qualitative approaches involve calculating interrater reliability. However, in exploratory
qualitative research, such as our study, discussion is more frequently used to resolve differences.
Inductive coding is deriving codes from the data. Deductive codes are predefined codes that come from
previous research. The form of coding used should fit the goals of the research. In our study, codes were
developed in several phases by two authors (JHN and MT) using a blended approach of deductive and
inductive codes.26 This approach kept the coding process open to interesting new data while remaining
connected to the scarce data currently available on this topic. Initial deductive codes were drawn from a
review of the literature. However, some of those codes were adjusted as novel and potentially important
information was elicited. The majority of the codes were developed through an inductive approach while
coding participants’ transcripts, which allowed the codes to remain accurate and relevant, representing
the reality of the participants as opposed to the beliefs of the researchers.
The first phase of code development used a descriptive approach, which identified emerging issues and
concepts surrounding the participants’ experiences. The second phase involved constructing patterns in
the data. This process consisted of identifying and refining the codes by groups and subdividing similar
and unrelated codes and creating and relabeling categories. In the last phase, the results were further
analyzed to determine how the new categories and subcategories were interrelated with one another.
An important analytic step is the development of a codebook. In qualitative work, codebooks organize
codes (themes or concepts) and typically include codes, subcodes, a definition of the code, and example
from the transcript and a description of when to use it or not use it (inclusion/exclusion criteria for the
codes). Definitions for codes were developed by reviewing all corresponding coded text. Similar codes
were combined, and infrequent codes were dropped. Inclusion and exclusion criteria were developed after
comparing codes to prevent overlap. Once a draft of the codebook was developed, it was applied to the
remaining transcripts and revamped when new codes were developed. The codebook underwent five
revisions before both authors agreed on a satisfactory version. See Table 2 for an example of the
codebook.
TABLE 2
Codebook example
Themes
Definition
When to use
When not to use
Examples
Concerns of
Patients describe their
Patient reports a
Patient describes
“I guess my biggest fear
death
fear of death at the time
concern about the
concerns about death as
is that I just walk
of diagnosis of VTE
possibility of dying as a
a result of treatment
around one day, grow a
and/or their continued
result of VTE
clot, and drop dead”
fear of death
“My biggest fear is
dying from it”
Other concerns Patient describes other
Any other concerns
Patient describes
“The scariest part for
concerns (different than
developed after and
concerns about
me was I wasn’t sure if
death) directly related to secondary to the
treatment, effects of
it (clot) would like
VTE
diagnosis of VTE
treatment, recurrence,
move to the baby”
(incomplete resolution
or death
of VTE, effects on
“I was worried about it
family)
(clot) moving”
Increased
Patient discussed the
Patient reported that
Patient discusses
“When somebody tells
stress after
negative impact that
their stress or anxiety
nonverbal
you are the most
communication verbal communication
level increased due to
communication that
interesting patient in the
with health
about VTE with their
communication about
increased stress (facial
emergency room, that’s
care provider
health care provider had VTE with their health
expressions, gestures,
probably not a good
Open in a separate window
In our project, all transcripts were independently coded by two authors (JHN and MT). An important part
of qualitative work is the explicit recognition of what the interviewers/coders brings to the table. The
coders filter data through their own experiences, creating interpretations of the data. In our study, one
coder was a practicing physician, while the other was a fourth‐year medical student. This was an explicit
choice, so that the coders would understand the medical information and the difference between
necessary care and overuse. Some argue that qualitative researchers should be outsiders, unconnected
with the phenomena under evaluation, and that only an outsider can be sufficiently impartial. However,
we argue that, whether insider or outsider, the interviewer always brings a specific lens to the interview.
Instead, the goals should be an explicit acknowledgment of one’s perspective and self‐awareness on the
part of the interviewer.
For the first six transcripts, both coders met in person to review and code transcripts together. The coders
spent ≈15 hours analyzing the first transcript, learning to navigate NVivo, initiating the development of
the codebook, creating new codes and discussing consistency of judgments between coders. Coding time
progressively decreased with each transcript. As the coders became more familiar with NVivo, more
codes were developed and readily available for application to each transcript and few differences between
coders arose. After transcript six, both coders independently reviewed and coded each transcript. Then,
the coders began online meetings (via Zoom) to establish consensus on the codes, formulate a general
description of the analysis, and to discuss emerging themes for each transcript. For codes identified later
in the coding process, earlier transcripts were reanalyzed for the novel codes. Differences among coders
were resolved by discussion. If the coders could not come to consensus, a third person (JAK) provided a
third opinion to help reach a final decision.
A myriad of qualitative analytic approach
