813112

article-commentary2019
QHRXXX10.1177/1049732318813112Qualitative Health ResearchViergever

Commentary
Qualitative Health Research

The Critical Incident Technique:

2019, Vol. 29(7) 1065­–1079
© The Author(s) 2019
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DOI: 10.1177/1049732318813112
https://doi.org/10.1177/1049732318813112
journals.sagepub.com/home/qhr

Roderik F. Viergever1

Abstract
The critical incident technique (CIT) is a qualitative research tool that is frequently used in health services research to
explore what helps or hinders in providing good quality care or achieving satisfaction with care provision. However,
confusion currently exists on the nature of the CIT: Is it a method for data collection and analysis or a methodology? In
this article, I explain why this distinction is important and I argue that the CIT is a methodology (and not a method)
for the following reasons: Key methodological dimensions are described for the CIT; it has a clear focus; studies that
apply this technique make use of various methods for data collection and analysis; it describes, explains, evaluates, and
justifies the use of a specific format for those methods; it implies philosophical and practical assumptions; and studies
that use the CIT cannot easily make use of additional methodologies simultaneously.

Keywords
critical incident technique; CIT; health services; research methodology; quality improvement; evaluation; qualitative
research; review; world

Introduction Redfern & Norman, 1999a, 1999b; Wendt et al., 2004)

The critical incident technique (CIT) was first described
scientifically by Flanagan in 1954 as a tool for formulat-
ing the critical requirements of an activity (Flanagan,
1954). That is, the CIT helps to understand the key things
people in a certain profession or activity should do—or
not do—in order for them to have the best chance of
achieving their goals. Although its origins lie with a pro-
gram that aimed to determine the critical requirements for
behaviors of pilots, the CIT was quickly picked up across
a range of disciplines (Butterfield, Borgen, Amundson, &
Maglio, 2005), including that of health services research
(FitzGerald, Seale, Kerins, & McElvaney, 2008; Wagner,
1950). Today, the tool has been used in a large variety of
qualitative studies in the dental sciences (FitzGerald et al.,
2008; Santha et al., 2016), nursing sciences (Bradbury-
Jones & Tranter, 2008; Clark, Lewis, Bradshaw, &
Bradbury-Jones, 2018; Kemppainen, 2000), primary care
(Redpath, Stacey, Pugh, & Holmes, 1997; Robinson,
Stacy, Spencer, & Bhopal, 1995), sexual health care (Clark
et al., 2018), hospital care (Runeson, Enskar, Elander, &
Hermeren, 2001; Stålberg, Sandberg, & Söderbäck, 2018;
Wendt, Fridlund, & Lidell, 2004), health care manage-
ment (Amati, Kaissi, & Hannawa, 2018), and to research
challenges in conducting health research (Getrich,
Bennett, Sussman, Solares, & Helitzer, 2016). It has been
used to explore both the views of patients (Björklund &
Fridlund, 1999; Peltola, Isotalus, & Åstedt-Kurki, 2018;
and of service providers on the quality of provided care
(Amati et al., 2018; Griggs, 2010; Redfern & Norman,
1999a, 1999b; Redpath et al., 1997; Runeson et al., 2001;
Stålberg et al., 2018).
Articles that have reviewed the CIT and its past appli-
cation are in disagreement on whether the CIT is a method
or a methodology. Some refer to it as a methodology
(Bradbury-Jones & Tranter, 2008; Kemppainen, 2000),
others as a method (Bradbury-Jones & Tranter, 2008;
Butterfield et al., 2005; Santha et al., 2016), yet others
use the terms interchangeably (Bradbury-Jones & Tranter,
2008; Flanagan, 1954; Gremler, 2004) and only rarely do
reviews discuss this important distinction (Bradbury-
Jones & Tranter, 2008; Byrne, 2001). An exception to this
rule is an article by Bradbury-Jones and Tranter, which
provides a detailed discussion of this issue and concludes
that the CIT can neither be a methodology nor a method.
The authors note that they are not able to formulate a
decisive view on how researchers are to overcome this
confusion (Bradbury-Jones & Tranter, 2008).
1
London School of Hygiene and Tropical Medicine, London, United
Kingdom
Corresponding Author:
Roderik F. Viergever, London School of Hygiene and Tropical
Medicine (LSHTM), London WC1H 9SH, UK.
Email: rviergever@research4health.org
1066
Given the frequent use of the CIT in qualitative health
services research (Bradbury-Jones & Tranter, 2008;
Kemppainen, 2000), the importance on clarity concern-
ing applied methods and methodology for any qualitative
research project, and the lack of clarity on how the CIT
should be viewed in this regard (Bradbury-Jones &
Tranter, 2008), further explication of the nature of the
CIT is needed. In this debate article, I will explain why it
is important to distinguish between methods and method-
ology, what the characteristics of a methodology are (as
opposed to a method), and also what the characteristics
are of the CIT. In doing so, I will argue that the CIT is a
methodology (and not a method).
Background on the CIT
Before I explain more about the difference between meth-
ods and methodology, and why that difference is impor-
tant, I give some general background on the CIT here.
In short, the “CIT explores what helps or hinders in a
particular experience or activity” (Butterfield, Maglio,
Borgen, & Amundson, 2009, p. 268). Whenever one can
reformulate the main research question of a study as
“what helps or hinders <fill in the experience or activity
under study>?” use of the CIT may be appropriate in the
study. In the context of health services research specifi-
cally, studies that may want to apply the CIT are those
that aim to acquire precise information on factors, events,
behaviors or experiences that result in satisfaction/dissat-
isfaction with care or that promote or detract from good
quality delivery of care (Bradley, 1992; FitzGerald et al.,
2008; Flanagan, 1954; Jones, 1988).
Such questions are commonly asked as part of qual-
ity improvement research. Using the CIT for this type
of research has several advantages that will become
clear later in this article and are described in the reviews
cited above. The main advantage of the CIT is also its
most important limitation: its high degree of focus on
things that help or hinder in a particular experience or
activity. This becomes clear from the five steps that any
CIT study has:
Step 1: Describe the aim of the activity under study.
Step 2: Make plans and specifications, including
defining the nature of a critical incident, its relevance
to and extent of effect on the aim, and the nature of
participants.
Step 3: Collect data on what participants perceive to
be factors, events, behaviors or experiences that help
or hinder in the experience or activity.
Step 4: Analyze the data collected in Step 3 by group-
ing the together identified critical incidents into over-
arching areas (and subareas) that have practical utility
in light of the aim of the study.
Qualitative Health Research 29(7)
Step 5: This step involves interpretation and reporting
of the results, in which particularly evaluation of limi-
tations and biases is stressed.
Because of the high degree of focus of the CIT on one
type of data (“what helps or hinders . . .”), the technique
is limited in the degree to which it engages with partici-
pants’ broader lives and psychological and sociological
backgrounds. Sometimes such information is needed as
part of a research study or may enrich the findings of a
study on quality of care. However, if you are looking
for a “clean” or “focused” overview of factors, events,
behaviors or experiences that result in satisfaction/dis-
satisfaction with care or that promote or detract from
good quality delivery of care, and of why those things
influence satisfaction with or quality of care, the CIT is
your methodology of choice (or method—at this point
in this article, the jury is still out on that one).
Examples of studies that have applied the CIT in the
field of health services research are studies with the fol-
lowing research questions:
•• What are positive and negative interpersonal
communication experiences, with doctors and
nurses, which either facilitated or impeded the
self-management of diabetes type 2 patients?
(Peltola et al., 2018)
•• What are the nontechnical skills that pediatricians
need to have in responding to a pediatric cardiopul-
monary arrest? (Walsh, Lydon, & O’Connor, 2017)
•• What are nursing actions that create a sense of
good nursing care in patients with wet age-related
macular degeneration? (Emsfors, Christensson, &
Elgán, 2017)
•• What are the key competencies for academic physi-
cians (so that faculty development initiatives may
target the development of those competencies)?
(Daouk-Öyry, Zaatari, Sahakian, Rahal Alameh, &
Mansour, 2017)
The Difference Between Methods and
Methodology
Definition of methodology: Methodology is concerned with
description, explanation, justification, and evaluation of the
process of scientific inquiry. (Carter & Little, 2007; Figure 1)
Definition of methods: The methods of a study are the technical
rules and procedures for data collection and analysis.
This difference between the terms methodology and
methods is important: While the methods constitute
merely the technical rules and procedures for data col-
lection and analysis, methodology is concerned with the
Viergever 1067

Table 1. Examples of Frequently Used Methodological

Approaches.

Methodological Approach Focus

Grounded theory Development of a general,
abstract theory of a process,
action, or interaction
grounded in the views of
participants in a study.
Phenomenology Understanding the essence of
experiences of a phenomenon.
Ethnography Understanding social
interactions, behaviors, and/or
perceptions that occur within
groups, teams, organizations,
or communities.
Participatory action To explore solutions to a
research problem and bring about
change in practice as part of
the research process.
Case study analysis In-depth exploration of a
program, event, activity,
process, or one or more
individuals.
Narrative approaches To investigate how people
experience life.

Note. This table is based on descriptions of methodologies by several

authors (Baker, Wuest, & Stern, 1992; Carter & Little, 2007; Cooper
& Endacott, 2007; Creswell, 2003; Lingard, Albert, & Levinson, 2008;
Rapport, Wainwright, & Elwyn, 2005; Reeves, Kuper, & Hodges, 2008).

Figure 1. The relation between a qualitative study’s

methodology, theoretical perspective, aim and problem type,
unit of analysis, methods for data collection and analysis, and
reporting format.
much broader description, explanation, justification, and
evaluation of the process of scientific inquiry (Carter &
Little, 2007; see Figure 1). Interviews, for example, are a
method of data collection, as are focus groups. Open
coding is an example of a method of data analysis.
However, grounded theory and phenomenology are
methodologies. The difference is that a methodology
provides guidance throughout a research study, offering
one approach that links the goal of the study to the unit
of analysis, to the methods for data collection and analy-
sis, and to the reporting format (Figure 1). Whether or
not the CIT is a methodology is therefore an important
question: If it is, it may guide researchers in answering a
particular type of question and in designing their qualita-
tive research process from beginning to end. If it is not,
it is merely a tool to be used, a procedure for data collec-
tion or analysis, for example. In that case, it may be
applied by a researcher as part of their research, but it
cannot provide guidance for essential questions, such as
why the study should use a unit of analysis or particular
methods of data collection or analysis. Also, in that case,
it will be easily usable as part of studies that apply other
methodologies. However, if the CIT is a methodology, it
generally will not be, because mixing methodologies in
one study has challenges (Annells, 2006; Baker, Wuest,
& Stern, 1992; Morse, 2010).
A key characteristic of methodologies (that sets them
apart from methods) is that methodologies have a specific
focus and are intended for use in specific studies, the aim
or research question of which is congruent with that focus
(Butterfield et al., 2005; Cooper & Endacott, 2007;
Creswell, 1998, 2007). Many methodological approaches
intended to guide qualitative research have emerged over
the years (Creswell, 1998, 2003; Tesch, 1990). Several
examples of such approaches along with the focus of each
approach are described in Table 1.
Besides focus, several other characteristics of method-
ologies are defined by various authors, who frequently use
these as dimensions to distinguish different methodolo-
gies from each other (Creswell, 1998, 2007; Patton, 2002).
For example, Creswell (2007) defines six such additional
dimensions besides focus: the type of problem best suited
for design, the discipline background, the unit of analysis,
data collection forms, data analysis strategies, and the
written report form. I will use these dimensions in the
remainder of this article in discussing methodology.
1068
CIT and Standard Methodological
Dimensions
To explore whether the CIT is a methodology or a method,
I describe in this section whether the CIT provides guid-
ance on Creswell’s dimensions noted in the previous sec-
tion (as a methodology would) or whether it merely
provides technical rules and procedures for data collec-
tion and analysis. Butterfield and colleagues (2005) have
already briefly applied Creswell’s framework to the CIT;
here below, I provide a more detailed account aimed at
exploring whether the CIT is a methodology or a method.
Besides providing these descriptions and explanations of
the CIT, I also explore whether the CIT literature pro-
vides justifications for its use and guidance for how to
evaluate it, which, as I noted in the previous section and
in Figure 1, are also characteristics of a methodology
(Carter & Little, 2007).
Focus
To ensure the coherence of a research project, it is impor-
tant that the focus of a methodology is congruent with the
aim of a research project (Cooper & Endacott, 2007;
DeForge & Shaw, 2012). A method for data collection,
such as interviewing, might, for example, be quite differ-
ently approached for studies with a phenomenological
approach than for those with a grounded theory approach,
due to differences in the aim of the study and thus in the
focus of the methodology (Annells, 2006; Wimpenny &
Gass, 2000). Many authors have discussed the foci of dif-
ferent qualitative research methodologies (Cooper &
Endacott, 2007; Creswell, 1998). One of the most elabo-
rate descriptions of the relation between research aim and
methodological focus is provided by Tesch (1990), who
created a diagram of 26 different research methodologies
matching with different research aims.
So does the CIT have such a focus? Yes; although it
has shifted somewhat since the CIT’s inception. Initially,
the technique was intended to facilitate the observation
and categorization of human behaviors for the purpose
of formulating the critical requirements of a particular
activity (Byrne, 2001; Flanagan, 1954). Flanagan (1954)
wrote, for example,
The principal objective of job analysis procedures should be
the determination of critical requirements. These requirements
include those which have been demonstrated to have made the
difference between success and failure in carrying out an
important part of the job assigned in a significant number of
instances. (p. 329)
He also wrote, “Essentially, the procedure was to obtain
first-hand reports, or reports from objective records, of sat-
isfactory and unsatisfactory execution of the task assigned”
Qualitative Health Research 29(7)
and “the cooperating individual described a situation in
which success or failure was determined by specific
reported causes” (Flanagan, 1954, p. 329).
Soon, however, applications of the CIT extended
beyond this focus. Categorizations were no longer lim-
ited to behaviors, but also included, for example, experi-
ences or program aspects. The purpose of the technique
broadened from formulation of critical requirements to
determining critical factors, events, behaviors or experi-
ences that promote or detract from the effective perfor-
mance of some activity or the satisfaction with that
activity (Butterfield et al., 2005). In short, as noted earlier
in this article, the “CIT explores what helps or hinders in
a particular experience or activity” (Butterfield et al.,
2009). I have found this latter definition a particularly
helpful tool to determine whether the CIT is the appropri-
ate methodology to use for a particular research aim:
whenever one can reformulate the main research question
as “what helps or hinders <fill in the experience or activ-
ity under study>?” use of the CIT may be appropriate.
In the context of health services research specifically,
this focus is analogous to acquiring precise information
on factors, events, behaviors or experiences that result in
satisfaction/dissatisfaction with care or that promote or
detract from good quality delivery of care (Bradley, 1992;
FitzGerald et al., 2008; Flanagan, 1954; Jones, 1988).
With regard to this focus, two notes need to be made.
First, a proportion of the health services studies that self-
report to apply the CIT appears to have a different pur-
pose: to understand service provider or patient/service
user behavior (Maddox, Tully, & Hall, 2011; Maharaj
et al., 2005; Miller, MacKeigan, Rosser, & Marshman,
1999; Scarton et al., 2018; Sverker, Östlund, Hallert, &
Hensing, 2009). In these cases, the CIT is used to under-
stand an activity, behavior, or experience (such as pre-
scribing behavior or adherence to medication), rather
than what helps or hinders in undertaking that experience
or activity. It is questionable whether use of the CIT in
these types of studies is appropriate given these studies’
deviation from the CIT’s originally intended focus.
Understanding behavior is very different from collecting
views on factors that help or hinder in undertaking an
experience or activity and investigators should consider
whether a different methodological approach might be
more suitable for pursuing this research aim. With studies
suitable for applying the CIT, the research question is
often a “WHAT-question,” that is, what factors help or
hinder in a particular experience or activity? This may
be followed—second—by a “WHY-question,” for exam-
ple, why do these factors help or hinder? However, the
primary research question is a “WHAT-question.” In con-
trast, with understanding behavior, the primary research
question is often a “WHY-question,” for example, why
do service providers prescribe in a certain way or why do
Viergever
patients not adhere to their medication? For these studies,
the use of other methodologies is more appropriate.
Second, as several authors point out, there has been a
proliferation of approaches and terminologies related to
the CIT over the past decades. Spin-off terms such as
critical incident analysis, critical event technique, criti-
cal incidents technique, critical incident exercise, critical
incident study technique, critical incident report, signifi-
cant event technique, significant event analysis, CIT
analysis, and critical incident reflection have all been
used to describe the approaches used in studies in the
past (Bradbury-Jones & Tranter, 2008; Butterfield et al.,
2005). Not all of these terms are synonyms for the CIT,
some describe different approaches. An often overlooked
difference is the difference between the CIT on one hand
and studies that conduct significant event analysis, criti-
cal incident reporting, or critical incident analysis on the
other (Bradley, 1992; Woloshynowych, Rogers, Taylor-
Adams, & Vincent, 2005). Cooper and colleagues first
deviated from the CIT’s original approach in 1978 using
this other type of analysis, aiming to study “preventable
anesthetic mishaps” (Cooper, Newbower, Long, &
McPeek, 1978). Cooper acknowledged that his approach
was a modified version of the CIT; later authors have
often neglected to recognize this deviation. Studies like
Cooper’s looking at adverse clinical events are often
referred to as a Critical Incident Analysis or Critical
Incident Reporting. Suggesting a similar adaptation for
the use of audit instead of research, Bradley (1992) pro-
posed the application of the principles of the CIT to ran-
dom case analysis to make it more reliable and robust,
giving rise to significant event analysis:
In significant event analysis, individual cases in which there
has been a significant occurrence (not necessarily involving
an undesirable outcome for the patient) are analysed in a
systematic and detailed way to ascertain what can be learnt
about the overall quality of care and to indicate changes that
might lead to future improvements. (Pringle, Bradley,
Carmichael, Wallis, & Moore, 1995, p. 2)
Hence, significant event analysis, as critical incident report-
ing/analysis, although applying some of the principles of the
CIT, is a systematic form of case review. The goal of these
approaches is to analyze cases in which there was a signifi-
cant outcome/occurrence. Therefore, significant event anal-
ysis and critical incident reporting/analysis are quite different
from the CIT: The unit of analysis in these studies is the
case, which in a regular case study can be anything from a
program to an event, activity, or process, to one or more indi-
viduals. In significant event analysis and critical incident
reporting/analysis, the unit is a significant (usually adverse)
event. In the CIT, however, the unit of analysis is the critical
incident, which may be a factor, event, behavior or
1069
experience that result in good or bad quality care. Critical
incidents might be, for instance, “Being able to delegate
well” as part of a larger category “Good leadership skills” or
“Being respectful and open to diversity” as part of a larger
category “Good communication skills.” The term “critical
incidents” is slightly misleading; really the unit of analysis
in the CIT consists of critical requirements for some experi-
ence or activity, still in line with Flanagan’s (1954) original
ideas about the CIT. As part of the CIT, participants are
always required to cite examples of when a critical incident
occurred, and THOSE might be considered cases, but criti-
cal incidents themselves are not. In other words, with the
CIT the whole spectrum of a person’s activities/behaviours
is observed or considered, of which a few are then chosen to
be critical requirements for some goal (with cases as exam-
ples of how the activities/behaviours contribute to that goal);
conversely, with significant event analysis, only specific
cases/examples/outcomes are reviewed (not the whole spec-
trum of one’s behaviours/activities).
A good review of studies that investigate adverse
events in health care is provided by Woloshynowych and
colleagues (2005). While the earlier of these studies con-
ducted interviews with staff and used open-ended ques-
tions about critical incidents, later studies moved toward
voluntary reporting of incidents, distancing themselves
further from the foundations of the CIT (Woloshynowych
et al., 2005). Due to the different foci of these studies, it
is important that in discussions on methodology they are
not grouped together with studies using the CIT method-
ology. As others, I would recommend that all studies that
do apply the CIT methodology, use the term critical inci-
dent technique (CIT), to avoid unnecessary confusion
(Bradbury-Jones & Tranter, 2008). All studies that do not
should not use the term CIT, for the same reason. That
said, it might be worthwhile to consider changing the
CIT’s name to “Critical Requirements Technique,” to
avoid confusion in the future between the CIT on one
hand, and significant event analysis or critical incident
reporting/analysis on the other.
Type of Problem Best Suited for Design
Those problems where there is a need to understand what
hinders or helps in some experience or activity are best
suited for a CIT study. With regard to health services
research, the type of problem is more specifically a need
to understand the factors, events, behaviors or experi-
ences that influence the quality of delivery of care or sat-
isfaction with that care.
Discipline Background
The origin of the CIT lies with Flanagan’s landmark arti-
cle from 1954 (Flanagan, 1954); its disciplinary origin is
1070
from the industrial and organizational psychology
(Butterfield et al., 2005). However, it is noteworthy that
the first application of the CIT in the health services
research discipline was published even before Flanagan’s
article (Wagner, 1950; the author was a student of
Flanagan) and an extensive amount of experience has
been gathered with the CIT’s application in the health ser-
vices sector over the past decades. A good overview of
how the method has evolved over time is provided by
Butterfield and colleagues (2005). Others have reviewed
the CIT’s application specifically in the health services
sector (especially in the nursing sector; Bradbury-Jones &
Tranter, 2008; Kemppainen, 2000).
Unit of Analysis
The unit of analysis in qualitative research ranges
widely and can include texts, persons, cases, social
interactions, processes, organizations, or incidents. In
case of the CIT, activities are analyzed and the unit of
analysis is the ‘critical incident’ (Gremler, 2004).
Critical incidents can be generally defined with regard
to health services research to be factors, events, behav-
iors or experiences that result in satisfaction/dissatis-
faction with care or that promote or detract from good
quality delivery of care (such as “the presence of a
host” in homes for the elderly or “keeping knowledge
up-to-date by attending at least X hours of post-univer-
sity training each year” as something that may deter-
mine the quality of care provided by a physician).
Critical incidents are commonly required to comply
with several requirements, including that an example
of the incident is given, the importance of the incident
to the participant is described, and that the helpful or
hindering incident is described in detail (Butterfield
et al., 2005; Kemppainen, 2000). Norman and col-
leagues have placed doubts on these requirements and
thus on the critical incident as the unit of analysis, and
have proposed to use “critical happenings” instead,
making inclusion possible of amalgams of multiple
incidents or incidents that cannot be precisely recol-
lected (Aveyard & Neale, 2009; Bradbury-Jones &
Tranter, 2008; Norman, Redfern, Tomalin, & Oliver,
1992; Reed, 1994). Flanagan (1954) suggested that
since the critical incident is the unit of analysis, satura-
tion for CIT studies should be defined in terms of criti-
cal incidents rather than in number of participants (i.e.,
saturation is reached when a predefined number of new
critical incidents does not give rise to the development
of any new themes). Given the great variability in the
number of critical incidents that are elicited per inter-
view per study, this makes estimating the number of
participants needed for a CIT study difficult (Bradbury-
Jones & Tranter, 2008; Gremler, 2004).
Qualitative Health Research 29(7)
Data Collection Forms
Although some authors argue that the CIT can be applied
both quantitatively and qualitatively (Chell & Pittaway,
1998; Gremler, 2004), CIT studies are commonly qualita-
tive (Butterfield et al., 2005), especially in the discipline
of health services research (Bradbury-Jones & Tranter,
2008; Kemppainen, 2000) and only rarely have a quanti-
tative component (Bradbury-Jones & Tranter, 2008;
Redfern & Norman, 1999a, 1999b). Qualitative data col-
lection as part of the CIT can make use of a variety of
different data collection methods including face-to-face
interviews, self-administered questionnaires, telephone
interviews, workshops, group interviews, systematic
record-keeping, and direct observation (Kemppainen,
2000). Flanagan (1954) described the CIT mainly as a
technique used in combination with direct observation as
opposed to retrospective self-report (while recognizing
the possibility of other methods for data collection,
including interviews). Nowadays, however, data are pri-
marily collected by means of face-to-face interviews
(Butterfield et al., 2005), which have even been described
by some to be “the most satisfactory data collection
method,” because it is able to supply the required detail
about critical incidents (Kemppainen, 2000).
Although the methods for data collection and analysis
under the CIT can vary, the CIT does outline a specific
format for data collection, regardless of the methods used
(Flanagan, 1954). Flanagan (1954) described the CIT as
having five procedural steps. Before commencing data
collection, Flanagan emphasizes the importance of
describing the aim of the activity under study (Step 1) and
to make plans and specifications, including defining the
nature of a critical incident (Step 2).
For Step 3, the actual data collection, information is
collected on what participants perceive to be factors,
events, behaviors or experiences that help or hinder in a
particular experience or activity. With regard to health
services research, this could, for example, be operational-
ized by asking patients, service users, carers, parents, or
service providers what has led them to be satisfied or dis-
satisfied with the care, what they found to be good or bad
about care provision, what they perceived to be examples
of high- or low-quality care provision, what their most
memorable experience was, or what kind of service pro-
vider behavior they found commendable or lamentable
(Kemppainen, 2000). Such a focused approach toward
data collection offers considerable advantages over
“freer” methods of data collection with regard to the aim
of studies using the CIT (i.e., investigating what helps or
hinders in a particular experience or activity). Several
notes deserve to be made with regard to Step 3 (data col-
lection). Butterfield proposed an enhanced version of the
CIT, the enhanced CIT (ECIT), in 2009, which prescribes
Viergever
the additional collection of contextual information and
views on “Wishlist-items” (care that was not present but
should have been; Butterfield et al., 2009). Furthermore,
as part of the process of data collection, Flanagan (1954)
stressed the importance of clearly explaining the purpose
of the study to participants. He also emphasized that it is
important that investigators pay due attention during data
collection to the criteria that define a critical incident so
that collected information is meaningful. Lewis (1994)
explains this well: “The opinion ‘receptionists are unhelp-
ful’ would not be useful. What is relevant are the specific
behaviours that create that impression, or which would
dispel it.” (p. 662)
Data Analysis Strategies
Step 4 of the CIT procedure as proposed by Flanagan
constitutes guidance for data analysis. Data analysis as
part of the CIT builds further on the focused form of data
collection that has taken place before. The process is
basically a modified thematic content analysis and is con-
cerned with grouping together identified critical incidents
in a manner that is most useful to the purpose of the
research. A useful description of the category formulation
process (based on Flanagan’s [1954] initial description of
this process) is provided by Bailey (1956):
Category formulation consists of the following steps: (1)
studying the behaviors intensively in accordance with the
purpose of the research; (2) formulating a rough classification
system which would seem to encompass the major areas of
the behaviors; (3) reclassifying the behaviors according to
the major areas formulated and revising the areas if
necessary; and (4) studying the behaviors within the major
areas grouping similar behaviors together to formulate
subareas, and writing specific descriptive statements to
cover similarities of the incidents. This process is repeated
until all of the behaviors are classified, and the general areas
contain a minimum amount of overlapping. (p. 59)
A more detailed description of the process is offered by
Butterfield and colleagues (2009).
In the process of data analysis, Flanagan (1954) stresses
the importance of selecting a general frame of reference to
guide the categorization of critical incidents and of deter-
mining “the most appropriate level of specificity-general-
ity to use in reporting the data.” (p. 346) Depending on
what the research is aiming to accomplish and what use is
made of the data, one could opt to report a few very general
overarching categories or many very specific categories.
Studies applying the CIT display the possible variance on
this issue and range from reporting 22 incidents to report-
ing 2,505 incidents (Gremler, 2004), and from data analy-
sis resulting in one layer (Runeson et al., 2001) to five
different layers (Redfern & Norman, 1999a, 1999b).
1071
Flanagan (1954) saw data analysis as part of the CIT
as being focused on grouping and categorizing critical
incidents: “The purpose of the data analysis stage is to
summarise and describe the data in an efficient manner
so that it can be effectively used for many practical
purposes.”(p. 345) He did not see a need for interpreta-
tion and stated that the only reason for doing any data
analysis at all (as opposed to just reporting the collected
critical incidents) is practical utility (Flanagan, 1954).
Rarely, CIT studies disagree with Flanagan and employ
a deeper form of analysis, combining descriptive content
analysis with an additional interpretive component as a
means of interpreting and understanding the data
(Gremler, 2004). Such additional analysis may indeed be
useful and suitable if it is relevant to the aim of the
research. A framework approach to data analysis could,
for example, be particularly suitable for this purpose,
following the same steps as the CIT analysis, but adding
an additional stage in which the relationships between
concepts or between concepts and characteristics of par-
ticipants are explored to create greater understanding of
the findings (Green & Thorogood, 2005). The collection
of additional contextual information, as suggested as
part of the ECIT that was proposed by Butterfield and
colleagues (2009), could also aid deeper analysis of the
data. Such an approach to data analysis could facilitate
obtaining more insight into the meaning of critical inci-
dents to (different) participants, as has been advocated
by Norman and colleagues (1992). It may also address
what some authors have called a “loss of information”
that may occur because participants’ narratives are trans-
formed into descriptive categories (Norman et al., 1992).
Some studies go even further and use interpretive meth-
ods for theme creation (Gremler, 2004). The possibilities
for using such an interpretive approach toward theme
creation as part of the CIT is discussed in more detail
under “Combining the CIT With Other Approaches” sec-
tion further in this article.
Written Report Form
The written report form of the CIT is that of categories
describing critical factors, events, behaviors or experi-
ences that help or hinder in a particular activity. These
categories are usually divided into subcategories, depend-
ing on whether there is a need for specific detailed data or
for overarching themes. Commonly, the reporting of cat-
egories is supplemented by the provision of excerpts
from the raw data, to provide further context to the identi-
fied categories. With regard to health services research,
this report form is commonly operationalized to reporting
categories of factors, events, behaviors or experiences
that result in satisfaction/dissatisfaction with care or that
promote or detract from good quality delivery of care.
1072
Evaluation and Justification
Step 5 of the CIT consists of guidance for interpreting and
reporting the findings of a CIT study. Evaluation is an
account of outcome, of whether expectations were met and,
possibly, of how worthwhile the study was in the estimation
of participants and others (Bassey, 1983). Flanagan (1954)
explains the importance of evaluation as part of the report-
ing process, in line with others who have advocated evalua-
tion procedures to increase the trustworthiness of a research
project (Lincoln & Guba, 1985). He states,
Each of the four preceding steps, (a) the determination of the
general aim, (b) the specification of observers, groups to be
observed, and observations to be made, (c) the data
collection, and (d) the data analysis, must be studied to see
what biases have been introduced by the procedures adopted.
(Flanagan, 1954, p. 346)
A significant step forward with regard to the CIT’s evalu-
ation procedures was proposed by Butterfield and col-
leagues (2009), as part of their suggested ECIT. They
recognized that previous attempts to establish the validity
and reliability of the CIT stemmed from a positivist
approach to qualitative research (Andersson & Nilsson,
1964; Koch, Strobel, Kici, & Westhoff, 2009; Ronan &
Latham, 1974) and that more procedures were needed as
part of the methodology to establish the trustworthiness
of a study employing the CIT, in accordance with trust-
worthiness checks as proposed by Lincoln and Cuba
(1985). Based on their experience with dozens of studies
employing the CIT that have used a variety of methods to
evaluate the CIT’s value and trustworthiness, they advo-
cate nine steps for the process of evaluation as part of the
CIT (Butterfield et al., 2005; Butterfield et al., 2009).
With regard to reporting the findings of the CIT specifi-
cally, Gremler (2004), reviewing the CIT’s past use in
services research, has made a useful contribution to the
methodology’s development by proposing a checklist for
reporting the findings of a CIT study, which may also be
used for evaluation purposes.
Justification of methods involves discussing the
merit of their use in the context of a wider setting, taking
into account alternative opportunities (Bassey, 1983).
The two main merits of the CIT in this regard are its nar-
row focus and the flexibility with regard to its applica-
tion (Kemppainen, 2000).
The very specific manner of data collection and anal-
ysis as part of the CIT ensures that acquired data are
consistent with the narrow focus of the methodology. As
Chell (2004) notes, “[it] enables the researcher to probe
aptly, and the interviewee to ‘hook’ their accounts” (p.
47). The narrowly focused data collection and analysis
has two advantages. First, it allows for very detailed
Qualitative Health Research 29(7)
data collection of exactly the type of information that is
needed, resulting in a deep understanding of partici-
pants’ views on what may help or hinder in a particular
experience or activity. As Kemppainen (2000) states,
“Unlike other qualitative methodologies that place
emphasis on describing phenomenon in naturalistic set-
tings, critical incident studies are more highly focused
on providing solutions to practical problems.” (p. 1265)
This makes the CIT useful for health services research,
the aim of which is to seek knowledge which will lead
to improvements in health care delivery and/or policies,
so as to improve the health of the public (Black, 1997;
Crombie & Davies, 1996). Second, it limits data collec-
tion that is not useful for the aim of studies to a mini-
mum, making its data collection and analysis more
succinct and efficient than with other methodologies
(Kemppainen, 2000). The fact that saturation of data
appears to be very quickly reached with CIT studies
demonstrates the high degree of focus of the methodol-
ogy (Butterfield et al., 2009; Coulter, Fitzpatrick, &
Cornwell, 2009).
The methodological flexibility that the CIT offers (by
allowing for various types of data and options for data
collection) also brings advantages to health services
researchers. The wide range of methods that can be used
to collect data for studies using the CIT means that the
approach can easily be adapted to suit different contexts
(Kemppainen, 2000).
The CIT’s flexibility, combined with its narrow focus,
makes it a suitable approach for many different health
services projects, ranging from audits (requiring succinct,
time- and cost-efficient data collection) to rigorous
research (requiring rich in-depth data collection, deeper
data analysis, thick reporting, and extensive evaluation).
Philosophy of Science and the CIT
Here above, I have described the CIT according to a set
of methodological dimensions and have explored
whether the CIT literature provides guidance for eval-
uation of the technique and for the justification of its
use. Some also consider the formulation of underlying
philosophical assumptions to be a part of methodology
(Jaye, 2002; Neale, 2009), although most consider this
to be separate (Carter & Little, 2007; Creswell, 2003).
Whether part of the methodology or not, the underly-
ing philosophical assumptions are commonly related
and specific to a methodology. Therefore, here below,
I explore whether a philosophical basis exists for the
CIT and whether it is accompanied by particular philo-
sophical assumptions, to shed further light on whether
the CIT should be viewed to be a method or a
methodology.
Viergever
Philosophical Basis of the CIT
The CIT was developed in a time when the positivist
approach to scientific inquiry was the dominant research
paradigm (Butterfield et al., 2005). This is reflected in the
characteristics of the CIT and its philosophical assump-
tions. Chell has suggested that the CIT makes several
assumptions that suggest a concreteness about reality
(Chell & Pittaway, 1998). Indeed, Flanagan’s (1954) arti-
cle suggests a positivist view of research. He writes, for
example: “The extent to which a reported observation can
be accepted as a fact depends primarily on the objectivity
of this observation. By objectivity is meant the tendency
for a number of independent observers to make the same
report.” (p. 335) In other words, according to Flanagan,
by comparing and integrating the independent and inher-
ently subjective views of different observers, a degree of
objectiveness can be reached with regard to the conclu-
sions and recommendations that follow from a CIT study
(Chell, 2004). However, he also recognized the limita-
tions of attempting to achieve an objective outcome, both
on the part of the participants (making inferences regard-
ing practical procedures for improving performance
based on observed critical incidents cannot be performed
with a high degree of confidence) and of the researcher
(classification of critical incidents is inductive and there-
fore necessarily subjective; Flanagan, 1954).
The question rises whether the CIT, given the above, can
also be applied in a post-positivist qualitative research tradi-
tion. Does an interpretivist research paradigm make the use
of the CIT as a methodology impossible? At first glance,
looking at Flanagan’s aims to formulate an objective view
about what influences an activity’s performance, it seems
difficult to apply the CIT within an interpretivist research
paradigm. In addition, many of the CIT’s assumptions,
which are described in more detail below, seem incongruent
with post-positivist paradigms. However, modern-day ideas
of qualitative research differ in some essential areas from the
views of qualitative research in Flanagan’s time. One of the
most pertinent differences is that modern, post-positivist
views of naturalistic inquiry assert that it is value-bound,
accepting that different participants necessarily have differ-
ent views of the same reality (or activity in case of the CIT)
and that one’s views are determined by previous experiences
and individual values (Lincoln & Guba, 1985). Flanagan,
speaking of factual reality and aiming for objectivity of
results, deviates from such views, but we must remember
that he developed the CIT in a positivist era. To justify the
CIT’s use within today’s qualitative research traditions, epis-
temological relativism needs to be married with the CIT’s
methodology—which is very much possible. Two modern
qualitative research paradigms seem particularly suitable to
facilitate this: the subtle realism (Mays & Pope, 2000) and
pragmatism (DeForge & Shaw, 2012) research paradigms.
1073
In these approaches, rather than the end-goal of research
being to provide an objective account of reality, these
approaches accept that perception of reality is necessarily
value-laden. Therefore, in these approaches, such a thing as
“objectivity,” inherently, can never be reached (Trochim,
2006). However, under these approaches, one could argue
that by comparing and integrating the inherently subjective
views of different observers, a degree of trustworthiness can
be reached with regard to the conclusions and recommenda-
tions that follow from a CIT study (rather than objectivity).
This conclusion is not so different from Flanagan’s views as
formulated at the beginning of this section and allows for
application of the CIT within a nonpositivist research tradi-
tion and for integration with its philosophical assumptions.
Given the pragmatic nature of the CIT (with a focus on
providing practical recommendations for improving per-
formance of an activity), pragmatism appears to be a
theoretical framework that is particularly well matched
with the CIT. Given the applied nature of the aim of
health services research (to seek knowledge which will
lead to improvements in health care delivery and/or poli-
cies, so as to improve the health of the public, Black,
1997; Crombie & Davies, 1996), this might be true espe-
cially for its application in the health services sector
(Bowling & Ebrahim, 2005).
Philosophical Assumptions
From the philosophical basis of the CIT follow several
philosophical assumptions. These are discussed here,
alongside other practical assumptions that the technique
makes:
•• The CIT is by nature an inductive, most often qual-
itative methodological approach (Butterfield et al.,
2005; Flanagan, 1954).
•• The CIT proposes that the role of the researcher
should be as objective as possible (although recog-
nizing that parts of the inductive data analysis pro-
cess are necessarily subjective). The researcher’s
purpose is to report participants’ views accurately.
(Conversely, other approaches view the researcher
to be a subjective actor in the knowledge creation
process, allowing the researcher, for example, to
engage with participants to jointly create under-
standing of a process or of how a phenomenon is
viewed, Annells, 2006). This assumption is
reflected in the proposed trustworthiness checks
by Butterfield and colleagues (2009), which are (in
part) aimed at minimizing and making transparent
the researcher’s influence on the data.
•• From Flanagan’s view that the results of a CIT
study should be as objective as possible (or as
“trustworthy” as possible, following terminology
1074
more commonly used in modern-day qualitative
research traditions), follows that the biases that
were introduced at several stages of the study have
to be carefully evaluated (Flanagan, 1954). Several
of the evaluation procedures as suggested by
Butterfield and colleagues aim to limit or make
transparent biases introduced by the researcher
(Butterfield et al., 2005; Butterfield et al., 2009;
Flanagan, 1954).
•• The CIT assumes that a purpose can be specified
for a given activity (Chell & Pittaway, 1998).
Without such a purpose, it would be impossible to
draw conclusions about what helps or hinders that
activity.
•• An important assumption of the CIT is that the
participant, whether an observer or an interviewee,
can make judgments regarding successful and
unsuccessful performance of an activity (Bailey,
1956). In the words of Flanagan (1954), “To be
critical, an incident must occur in a situation where
the purpose or intent of the act seems fairly clear to
the observer and where its consequences are suf-
ficiently definite to leave little doubt concerning
its effects.” (p. 327)
•• From this it follows that, when using the CIT, data
analysis is mainly descriptive. The CIT aims to col-
lect views on what might help or hinder some expe-
rience or activity. Although it recognizes that views
between observers might differ, one of the key
aspects of the methodology is the above-mentioned
assumption that participants can make judgments
regarding successful and unsuccessful performance
of an activity. The CIT’s purpose is to collect and
report those judgments in a manner that is most
useful. As several authors stress, wholly interpre-
tive approaches to theme creation appear in princi-
ple incongruent with this purpose (Butterfield
et al., 2005; Byrne, 2001; Grant, Reimer, & Hrycak,
1993; for an exploration of whether such approaches
may be successfully used with the CIT, see
“Combining the CIT With Other Approaches” sec-
tion). However, as discussed earlier, additional
interpretive analysis beyond descriptive theme cre-
ation to acquire a deeper understanding of the data,
of relations between concepts, and between con-
cepts and participants’ characteristics is not neces-
sarily incongruent with the CIT and could provide
the enrichment of data that some authors call for
(Norman et al., 1992).
•• Other practical assumptions that the CIT makes are
that the object of study is an activity and the unit of
analysis is a critical incident. Not all assumptions of
the CIT have gone unchallenged over time and the
following have all caused substantial debate:
Qualitative Health Research 29(7)
Flanagan’s presuppositions that a critical incident
must refer to a clearly demarcated scene; that a
detailed account must be obtained from the observer
about what happened and that otherwise the incident
should not be considered valid; and that the critical
incident is the unit of analysis. Especially, Norman
and colleagues (1992) have argued for an approach
based on “critical happenings,” that can be an amal-
gam of past experienced incidents and do not neces-
sarily have to be described in detail. The core of the
disagreement lies in Flanagan’s belief that only
detailed accounts can be trusted to be objective/trust-
worthy accounts of reality, whereas Norman and col-
leagues argue that also less detailed accounts or
amalgams of past experiences that are not clearly
demarcated may be valuable. Some researchers agree
with the analysis by Norman and colleagues
(Bradbury-Jones & Tranter, 2008; Reed, 1994); oth-
ers with Flanagan’s (Grant et al., 1993). Although
these two views might appear to be at odds with each
other, they might be unifiable. Investigators could, if
they wish, strive for detailed accounts and for infor-
mation on concrete examples of demarcated events,
but nonetheless reserve the freedom to include other
incidents or happenings that appear to be valuable to
them. Another practical assumption on which some
disagreement exists is Flanagan’s presupposition that
agreement among different participants on a critical
incident increases the trustworthiness of the incident
(Flanagan, 1954). Some authors propose to only
include critical incidents that are frequently men-
tioned (e.g., at least 25% of participants; Butterfield
et al., 2005); others caution to take frequency alone
as a measure of importance for a critical incident
(Andersson & Nilsson, 1964; Jones, 1988).
Combining the CIT With Other
Approaches
Finally, here below I explore to what degree the CIT has
been used in conjunction with other approaches and what
that means for the CIT’s status as either a method or a
methodology.
Mixing different qualitative methodologies may have
advantages, such as obtaining a different perspective
through different data or a different level of analysis,
allowing one to answer a research question more fully
(Morse, 2010), but may risk leaving studies with a lack of
internal coherence and hence credibility (Annells, 2006;
Baker et al., 1992; Morse, 2010). Several authors describe
how the use of multiple methodological approaches in one
study may be appropriate if (a) there is a good fit of the
approaches with the research problem and questions; (b)
the approaches fit well with each other, especially
Viergever
concerning the underlying philosophical paradigm; and
(c) the integrity of each approach is maintained, meaning
that there are distinct objectives for each approach (cor-
responding to the different foci of the approaches), as well
as distinct phases of analysis and, depending on the meth-
odologies that are mixed, potentially different data collec-
tion phases (Annells, 2006; Morse, 2010).
If the CIT is a method (instead of a methodology), it
should be easily integrated into other approaches without
applying these criteria. However, looking at examples of
such integration, it becomes clear quickly that problems
arise from attempting to unify the characteristics of the CIT
with other approaches. Let us look, for example, at integra-
tion with grounded theory. How would one unify the theo-
retical sampling approach of grounded theory and its
continuous comparison approach to data collection and
analysis with the methods as advocated by the CIT as
described above? How would one unify the grounded theory
approach to data analysis, in which it is common to “break
up” the data (Green & Thorogood, 2005), with the CIT’s
method for data analysis in which it is important that partici-
pants’ accounts are preserved and accurately prescribed?
How would one unify the clarity on outcome that goes with
use of the CIT (factors that help or hinder in a particular
experience or activity) with the uncertainty on outcome with
use of the grounded theory approach (theory development—
but which theory is often not sure when the research com-
mences)? Given the specific focus of the CIT, its specific
guidance for data collection and analysis, and its philosophi-
cal assumptions, the CIT cannot be easily unified with other
methodologies (that have equally specific methodological
characteristics), unless the three criteria listed above are
applied, which guarantee that the integrity of both approaches
is preserved. This holds true for the integration of all other
methodological approaches, as well. This provides addi-
tional evidence that the nature of the CIT is a methodology
— not a method.
Gremler (2004), in reviewing the application of the
CIT in services research, found self-reported application
of the CIT has been combined with the application of
other methodologies in the past in two different ways.
Either the CIT is used to produce data that were not the
primary focus of the study but to complement data col-
lected as part of the dominant methodology used in the
study, or the CIT methodology is followed but an
approach to data analysis from a different methodology is
used for thematic development.
Bradbury-Jones and Tranter (2008) also provide exam-
ples of modes of combining the CIT with other methodolo-
gies within the health services research field. When these
examples are explored in detail, a picture emerges that
largely confirms Gremler’s finding that there are two groups
of studies that combine the CIT with other methodological
approaches. First, there is the group of studies that apply the
1075
CIT within another, primary methodology. These studies are
often studies that use a methodology other than the CIT but
incorporate some elements of the CIT in their approach: for
example, the focus on specific incidents or asking about
what helps or hinders in a particular activity as part of data
collection (Conway, 1998; Silen-Lipponen, Tossavainen,
Turunen, & Smith, 2004; Silen-Lipponen, Tossavainen,
Turunen, Smith, & Burdett, 2004). It is noteworthy that nei-
ther of these automatically makes a study a CIT-study. I
myself have conducted research in which I asked partici-
pants about what helped or hindered in good quality care
provision (Viergever, 2016), but this study was wholly based
in grounded theory. It merely applied an element that is
shared with the CIT—asking about what helps or hinders in
an activity. However, as has become clear above, applying
the CIT as a methodology implies a range of other data col-
lection and analysis procedures. None of these were applied
by me and therefore I did not report to have applied the CIT.
In reality, the studies that use a methodology other than the
CIT but incorporate some elements of the CIT in their
approach and self-report to apply the CIT mostly do not
adhere to the CIT’s principles or apply the methods for data
collection or analysis that belong to the CIT. Therefore,
these studies generally cannot be said to apply the CIT.
Second, the other group of studies that combine the CIT
with other methodologies employ a CIT approach and
have research aims and methods for data collection that are
congruent with the CIT, but make use of an interpretive
data analysis technique (Aveyard, 2002; Aveyard &
Woolliams, 2006; Wolf & Zuzelo, 2006)—as opposed to
the descriptive data analysis procedures as prescribed by
the CIT (see above). For some, although the studies men-
tion use of an interpretive analytical procedure, for exam-
ple, the method of constant comparison, it is unclear
precisely what data analysis procedures were used and
why an interpretive approach to data analysis was chosen
(Aveyard, 2002; Aveyard & Woolliams, 2006). For others,
the approach to data analysis is well described and clearly
diverges from the CIT, but again no explanation is offered
for why the researchers deviated from the standard CIT
methods for analysis (Wolf & Zuzelo, 2006). This is some-
thing that should be addressed in future studies taking such
an approach. To ensure that coherence of the research aim,
the philosophical foundations, the methodology, and the
methods for data collection and analysis is maintained, as
described above, it is important that the mixing of methods
is well described and justified. Finally, several other stud-
ies show that it is possible to use interpretive approaches to
data analysis as part of (an adapted version of) the CIT,
while describing and justifying their application ade-
quately. The first of these studies, by von Post (1998), used
a hermeneutical approach to data analysis. Her approach
was later repeated by Karlsson and Lindberg (Karlsson,
Bergbom, von Post, & Berg-Nordenberg, 2004; Lindberg
1076
& von Post, 2006). Von Post (1998) explains well why this
approach was taken and argues that a hermeneutical
approach to data analysis may be combined with a method
that originates from a positivist perspective such as the
CIT. The consequence for her research is that she no longer
is an objective observer, but plays an active, interpretive
role in the data analysis process based on her expertise in
the field of study. Although this is a clear deviation from
the positivist, objective approach that the CIT as proposed
by Flanagan advocates, it is a well-reasoned and valid
choice that does not cause an incoherence between the
research aim, methodology and methods (the goal of dis-
covering what helps or hinders in an activity is still present,
it just also incorporates the researcher’s own views as an
expert, instead of only the views of participants). This
study can no longer be purely called a CIT-study, but might
be called an “adapted version of the CIT.” That said, von
Post provides an excellent example of how the CIT can be
combined with other methodologies, by providing a justi-
fication for that combination and showing that coherence
between the research aim, philosophical foundations,
methodology and methods is preserved.
Therefore, from this section on combining the CIT with
other approaches, it can be concluded that the CIT may be
combined successfully with other methodologies by (a)
applying the three criteria with which this section started,
or (b) modifying it into an “adapted version,” incorporat-
ing methodological aspects from another methodology
into the CIT (but only when such adaptations are well
explained, justified, and do not cause an incoherence
between the research aim, philosophical foundations,
methodology and methods).
Conclusion
The CIT is a qualitative health research technique that
aims to provide suggestions for the improvement of how
some activity is performed (to increase the likelihood
of ‘successfully performing’ that activity). This article
does not intend to provide a comprehensive overview of
all aspects of the CIT nor to review its past application
in health services research; this has already been done
by others (Bradbury-Jones & Tranter, 2008; Butterfield
et al., 2005; Butterfield et al., 2009; Gremler, 2004;
Kemppainen, 2000). It intends solely to address the con-
fusion that currently exists on the methodological nature
of the CIT. By explaining what the characteristics of a
methodology are and what the characteristics of the CIT
are, I argue here that the CIT is a methodology, and not
a method, for the following reasons:
1. Key methodological dimensions (i.e., focus, type
of problem best suited for design, discipline back-
ground, unit of analysis, data collection forms,
Qualitative Health Research 29(7)
data analysis strategies, and written report form)
can be described for the CIT.
2. In particular, the CIT has a clear focus that sets it
apart from other methodological approaches and
makes its application appropriate for studies that
aim to investigate what helps or hinders in some
experience or activity.
3. The CIT has the characteristics of a methodology,
in that it describes, explains, evaluates and justi-
fies the use of a particular unit of analysis, par-
ticular methods for data collection, particular
methods for data analysis, and a particular report-
ing format.
4. Studies that use the CIT can make use of a range
of different methods (including various types of
data and methods of data collection), even though
those methods are all applied in a way specific to
the CIT.
5. Using the CIT implies several philosophical and
practical assumptions.
6. Studies that use the CIT cannot easily make use of
different methodologies simultaneously; in doing
so problems arise with unifying the different foci
of the approaches and their methods for data col-
lection and analysis.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Roderik F. Viergever https://orcid.org/0000-0001-5328-2580
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Author Biography
Roderik F. Viergever is a medical doctor who also holds
degrees in (astro)physics and international public health and
doctorates in health services and health policy research. He is
particularly interested in public health and social policy and
focuses on strengthening the rights of and services for vulnera-
ble and marginalized populations.