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European Journal of Dental Education ISSN 1396-5883

Doing qualitative research in dentistry and dental education


S. Edmunds1 and G. Brown2
1
University of Westminster, London, UK,
2
University of Nottingham, Nottingham, UK

Keywords Abstract
qualitative research; dental education; dentistry;
methodology; pedagogy. The purpose of this paper is to assist dental researchers to develop their expertise in
qualitative research. It sketches the key characteristics of qualitative research; summa-
Correspondence rises theoretical perspectives; outlines the core skills of qualitative data collection and
Dr Sarah Edmunds the procedures which underlie three methods of qualitative research: interviewing,
University of Westminster focus groups and concept maps. The paper offers some guidance on writing qualitative
Department of Psychology research and provides examples of qualitative research drawn from dentistry and dental
309 Regent Street education.
London W1B 2UW, UK
Tel: +44(0)207 911 5000 ext 2170
Fax: +44(0)207 911 5106
e-mail: s.edmunds1@westminster.ac.uk

Accepted: 15 December 2011

doi:10.1111/j.1600-0579.2011.00734.x

research nor with the detailed differences in methods (6, 7).


Qualitative methods Rather, it provides a guide to qualitative research and its major
Qualitative methods encompass open-ended questions in ques- methods for use by dental researchers.
tionnaires, interviews, focus groups, electronic discussions,
observation of practical procedures, presentations and analyses
of written documents. These methods in dentistry and dental
Characteristics of qualitative research
education are becoming recognised as powerful research tools Qualitative research may be described as arts-oriented rather
(1). They are important as adjuncts to the familiar methods of than scientifically oriented. It is primarily concerned with
quantitative research and as methods in their own right (2, 3). words and their meanings in different contexts whereas quanti-
In dentistry, qualitative methods may be used to explore the tative research is predominantly concerned with numbers and
anxieties or attitudes of patients, expert patients or members of their significance. Summarising themes, rather than counting
dental specialities towards modes of treatment. In the broad and measuring, is the keystone of qualitative research. Instead
domain of dental education, they may be used to investigate of testing hypotheses through the use of experiments or surveys
the relationships between professional groups, such as dentists and applying statistics or mathematics to the data collected,
and the dental team, between professional groups and manag- qualitative researchers collect and analyse the themes in obser-
ers and to reveal attitudes towards policy, organisation, man- vations, transcripts or documents. Often qualitative researchers
agement and new practices. Within this broad domain, work with small samples of participants. They do not make
qualitative methods can be used to explore the special field of bold claims based on the statistical generalisability of their find-
dental pedagogy and its concerns with teaching, learning and ings. Instead, the reader is free to decide whether the findings
assessment in the contexts of courses and clinical education. of the research ring true for them (8).
This paper provides a sketch of the major characteristics of The above characteristics of qualitative research may pose
qualitative research and some guidelines on conducting qualita- threats to dental researchers who believe that there is only one
tive research in dentistry and dental education. It is not a ‘true’ (quantitative) way of doing research, to teachers of den-
review of the use of qualitative methods in dentistry (3–5); it is tistry who do not wish to change their approach and to school
not concerned with the esoteric arguments in qualitative administrators or hospital managers who are reluctant to

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Eur J Dent Educ 16 (2012) 110–117
Edmunds & Brown Doing qualitative research

change the structure of degree programmes or the organisation dentistry in the 19th Century is not usually regarded as good
of clinical education. Yet, these characteristics can be beneficial dentistry today; the meanings (perceptions) attached to a par-
as qualitative research often reveals insights which standard ticular type of dental surgery may be different for dentists,
quantitative methods do not capture. These insights may be nurses, technicians and patients. To add to the confusion, some
about thoughts, feelings, attitudes or anxieties of staff (faculty), qualitative researchers point out that what is regarded as
students or patients. For example, the inner feelings of patients ‘objective’ is sometimes merely inter-subjective agreement (18).
suffering from oral cancer are not easily revealed in large-scale Constructivism is much more complex and diffuse than pos-
epidemiological surveys but are revealed in qualitative studies itivism, and there are wide variations in the paradigms and
(9). The insights may provide information or perspectives belief systems held by qualitative researchers and the methods
which a researcher had not considered. These insights can then they use.
be published in their own right or used as the basis of a larger Dentists and dental educators new to qualitative research are
quantitative or ‘mixed methods’ survey (10–13). likely to start with a problem or question which they wish to
It would be wrong to leave this account without pointing investigate and not to consider underlying theoretical
out three features of qualitative research which are often mis- approaches. Nonetheless, consideration of the broad theories
construed by dentists who are more familiar with ‘scientific’ or beneath any qualitative research study can be useful as this pro-
more precisely, positivist approaches. The first is that quantita- vides a framework within which the quality and rigour of the
tive researchers sometimes think that qualitative researchers are study and its core research questions can be considered.
not concerned with rigour they are, but in line with their view Table 1 provides a description of theoretical approaches, com-
that words and their meaning are more important than num- mon methods and examples of studies in dentistry and medi-
bers and their significance, few are concerned with the minutiae cine. It should help those new to qualitative research who wish
of statistical generalisability, reliability and validity. Their crite- to orient their study within a theoretical approach. However,
ria of rigour include transparency, triangulation, clear exposi- readers are warned that there are arguments in the literature
tion of procedures findings and analyses, validation of the data about the extent to which theoretical approaches have a direct
collected by the respondent(s), providing background details of correspondence to particular qualitative methodologies and
relevant aspects of the belief system of the researcher and, methods (19).
where appropriate, placing the findings in a theoretical context We outline below the core skills and methods of qualitative
or earlier research (14). Many of these broad criteria are in line data collection and analysis which are common in oral health
with those of quantitative researchers. science research.
The second and related misconception is that quantitative
and qualitative researches are methodologically entirely separate
The core skills of qualitative data
domains. In fact, qualitative researchers, particularly those
collection
using grounded theory, require coding, counting and some-
times measurement. Quantitative researchers in discussion sec- Regardless of the perspective taken by a qualitative researcher,
tions of articles often offer insights and speculations which the fundamental principle underlying most data collection in
might be classified as qualitative. In both forms of research qualitative research is ‘Ask open questions and listen actively’.
what matters most is the nature of the research problem and The exceptions to this principle are qualitative observation and
choosing methods which fit the research problem. It could be documentary analysis. In qualitative observations, observers
argued, therefore, that qualitative and quantitative research note what they see and hear (26). In qualitative documentary
should be seen as complementary rather than oppositional analysis, the researcher interrogates the text and identifies the
approaches to research. underlying themes, not merely its ostensible purposes. It is also
worth noting here that open-ended questions tacked to the end
of structured questionnaires usually have low response rates
Theoretical perspectives
and rarely yield valuable information.
The third theoretical feature is more challenging. Qualitative
and quantitative research differ philosophically as well as in
Open questions
their understanding of what ‘knowledge’ actually means (15).
Quantitative research is based on the assumption that there is Open questions give participants freedom to express their own
an objective, real world independent of our perception and it is opinions or reveal their knowledge. In interviews, they can be
knowable. Quantitative researchers consider knowledge of that roughly classified as spontaneous or guided. Spontaneous ques-
world should be studied using observational or experimental tions are those that spring to mind. They can obtain unex-
methods based on measurement and probabilities (positivism) pected and valuable information. Guided questions are
(16), and these will lead to a better understanding of the nature deliberate steers in an interview or discussion but they are not
of the real world. Most qualitative researchers in the health sci- leading questions. ‘What are your views on invisalign and stan-
ences do not deny the existence of a ‘real’ world, but they do dard braces?’ is an example of a guided question which could
assert that we construct our own meanings of that world and be asked of orthodontists or of teenagers. (The question will
its objects, and those meanings are shaped by our experience, have a different meaning to these different participants.) ‘Do
history and culture. The collective term for this assumption is you actually prefer invisalign to standard braces?’ is an example
constructivism (17). For example, what novices and experts see of a leading question. Guided questions can be standardised
in an oral radiograph may differ; what was regarded as good and thereby provide some control of the data collection. But

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Doing qualitative research Edmunds & Brown

TABLE 1. Theoretical approaches in qualitative research

Theoretical
approach Description Methods Example studies

Ethnography The study of social interactions, Often uses a combination of Balmer et al. (22) investigated bedside
behaviours and perceptions that observations and interviews. Analysis teaching in general paediatrics as a
occur within groups, teams, involves triangulation (comparison social phenomenon and explored
organisations and communities(20). It between data sets) to enhance change over time in both the
is argued that observation of a group quality of the findings meaning of rounds and the context
or organisation over a long term, in which rounds take place.
leads to the identification of the Observations were made of normal
webs of meanings or schemas of the ward activities over 8 months, and
‘insiders’ views (21) interviews were carried out with
physicians, junior doctors and
medical students. Inductive thematic
analysis was conducted. For further
example studies see (23–26)
Phenomenology Aims to provide accounts that offer Often uses one-to-one interviews Examples are the studies by Wolf et al.
insight into the ‘lived’ experience of which are transcribed with the (27) of chronic orofacial pain; Roing
individuals. To understand this paralinguistic cues included (um’s et al.’s (9) study of patients’
experience of a person or group, one er’s hesitations, stumbles, emphases) experience of oral cancer; Bowers
needs to put aside one’s own and Wilson’s (28) study of dental
pre-conceptions and focus on what hygienists training; and Jahangiri’s
experiences mean to the participants study of the characteristics of
involved (19) effective classroom teachers as rated
by students and professionals (29)
Grounded Theory Aims to generate a higher level of Typically uses one-to-one interviews There are many examples of the uses
understanding about social and focus groups. Documentary of grounded theory in dentistry and
interactions or experiences that is analysis can be used. Data collection dental education (33, 34) but, as yet,
‘grounded’ in, or derived from, a and analysis is an iterative process, no comprehensive review of their
systematic analysis of data. Grounded and the theory is evolved as further uses
theory is appropriate when the study data are collected. The data may be
aims to explain a process, not to test analysed using ‘open coding’ or
or verify an existing theory. The ‘closed coding’ (Cf framework
original and rather tortuous theory of analysis)
Glaser and Strauss (30) now has
many variants (31, 32)
Qualitative Strictly speaking not a theoretical Over the long term, it may involve We have not discovered any published
Observational approach but rather a method that covert participant observation as in reports of qualitative observation
Research can be linked to many approaches ethnography, but it can also be used research in dentistry but it could
(35). Qualitative observation can in brief encounters in which the provide useful insights into skills,
report what people say and do rather observer is a covert participant or procedures and relationships in
than just what they say they do. It is simply a known observer. These dental education and professional
the systematic watching and listening natural settings might include practice
to people and events in ‘natural’ patients’ waiting rooms, wards,
settings’ rather than in controlled operating theatres, laboratories,
experiments clinics, departmental meetings
Narrative Methods of recording, analysing and The basic method consists of The approach has not yet been used
Research interpreting the stories of participants recording the story, as told by the extensively in dental research but it
(Narratology) so as to make sense of participants’ participant(s), with only a few has rich potential for, for example,
experiences. It is assumed that the prompts from the researcher about exploring patients’ experience of oral
analysis of the content, structure and the storyline, the participant’s health care and trainees’ stories of
context of the stories will reveal perceptions of the characters their training years. Critical incident
common themes and meanings (36) involved and the particulars of the techniques can be regarded as a
setting. There are different special form of narrative research
approaches to interpreting the stories (33). Examples of dental stories can
(37, 38) but all share the be found at http://www.healthangle.com/
commonality of analysing the reports topics/dental/stories and
of the sequence of personal events http://dentalphobiastories.tripod.com
and related ideas

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Edmunds & Brown Doing qualitative research

TABLE 2. Dimensions of questions TABLE 3. Examples of probing questions

Open – closed
Recall – thought } For all qualitative investigations
Why did you do that? Looking back, can you see
any connections?
Encouraging – threatening Do you still think that? How do you see it now?
Clear – confused
} Particularly important in
oral-based investigations
Can you give me an example of that? What made you change
your mind?
You say it is an x, what kind of So, what’s different?
an x was it?
one must be careful: a change in emphasis of a word can Could you provide more detail on that? What seems to have stayed
change the perceived meaning of the question and consequent the same?
responses of participants. Tell me a little more… What’s so different now?
Questions can be categorised along four dimensions, which What did you enjoy? Why did you feel that way?
are given in Table 2. The dimensions can be used to check with What was difficult for you? What do other students think?
a few critical friends if the questions are likely to provide inter-
esting lines of enquiry. These dimensions are relative to the
background of the participants. What is a simple recall ques-
tion to a dental postgraduate may be a thought question to a
first-year dental undergraduate. Researcher talks Participant talks
The sequence of questions is important in qualitative
Participant listens Researcher listens
research. Usually, it is better to begin with open questions, and observes and observes
which the participants can answer easily, and then proceed to
more challenging or sensitive questions and end with summa-
rising questions which maybe closed questions and a thanks. Fig. 2. Two-way process of active listening.
This approach gives the participants confidence not only in
themselves but in the researcher so they leave the interview or
focus group with a feeling of satisfaction. listens to what the other says. Two recent publications provide
It is important to consider possible follow-up questions one further details of the styles and processes of listening (39, 40).
might ask, as well as broad, open questions. A useful sequence
is given in Fig. 1.
Main methods of qualitative data collec-
Examples of probing questions one may use in interviews or
tion
discussions are given in Table 3.
Prompting questions give participants a range of choices Of the many methods of data collection in qualitative research,
such as ‘Is it because it’s boring? Too difficult? Too easy? Not rel- three are of particular value in research in dental education
evant? You don’t see the point of it? Any of these?’ One should and dentistry. These are interviews, focus groups and concept
use prompting questions sparingly in open interviews. (Some maps. All require a clear specification of the research question
purists think they should never be used.) Providing a broad and careful design of the procedures.
range of choices are offered, prompting questions can stimulate Interviews, group interviews and focus groups (41) are based
the participants to think. on open questions and active listening. Both can yield rich
information for use in their own right, as a preliminary to a
larger-scale research, or as in-depth exploration of themes
Listening actively
which emerged from a large-scale survey.
As in the dental consultation, active listening is important in
qualitative research. Listening actively involves attending to
Interviews
what is said and not said. Hesitations, stumbles and tone of
voice convey meaning in telephone and face-to-face interviews. Qualitative interviews may be described as ‘conversations with
In face-to-face interviews, body language conveys additional a purpose’: they are not interrogations. The conversation may
cues. These cues are part of the two-way process (see Fig. 2). be meandering and seemingly casual, or the conversation may
In a smooth conversation or discussion, there is a steady be based on a sequence of open questions. The purpose of the
flow of turn-taking. This flow and its cognitive processing can open questions is to obtain answers to broad research ques-
be disrupted if either the researcher or participant talks too tions. The interviews may be face to face, video linked, online
slowly or too quickly or if neither researcher nor participant or by telephone. Skype is useful for video interviews, but these

Open Participant’s Probing Prompting


Pause question (if
question response question
necessary)

Fig. 1. Sequence of questions.

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Doing qualitative research Edmunds & Brown

are currently not easily recorded. Face-to-face interviews pro- group and allow for some digressions by the participants from
vide the richest data, and they are the preferred mode of opera- the main themes.
tion. Interviews based solely on highly structured forms which Focus groups provide rich data in many contexts, but they
require only box-ticking are a waste of resources: one might as are open to manipulation by an unscrupulous facilitator and
well distribute a structured questionnaire. For examples of the they are not appropriate for dealing with highly sensitive issues.
use of qualitative interviews in dental research and dental edu- Trust between participants and between participants and the
cation, see Victoroff and Hogan (42) and Ayers et al. (43). facilitator is vital to their success. Self-disclosure is not always
forthcoming in focus groups. Dominant participants (power
talkers) can sway the expressed views of a group. If the power
Focus groups
talker takes a particular view, then others are likely to agree
Focus groups are focussed discussions: they are not group even if they disagree (and sometimes say so after a focus
interviews. In group interviews, the conversation is primarily group). Examples of the use of focus groups in dental research
between the interviewer and each of the participants in turn. In and dental education are given by Gallagher et al. (45), Ashley
focus groups, conversation is mainly between participants with et al. (46), Bearn and Chadwick (47) and Brondani et al. (48).
input from the interviewer when required to guide its direc- It is preferable to record data from interviews and focus
tion. Fig. 3 highlights these differences. groups in an audio format. Taking detailed written notes can
Focus groups are usually face-to-face events although it is be distracting for the researcher and threatening for the partici-
possible to organise video-linked focus groups if one wants to pants. Audio- or video-recordings provide opportunities for re-
involve participants from different geographical areas. The visiting the data, but one must ensure that the data are
composition of a focus group is, ideally, determined by the recorded accurately. Swearing afterwards may be cathartic but
purpose of the research. Hence, the group may be homogenous it will not bring back the data. Digital recordings of audio data
(e.g. all bright students, all General Dental Practitioners), heter- permit downloading to PCs or Macs so it can easily be copied,
ogeneous (from different dental departments or schools), well stored, edited, transmitted or transcribed.
established (have worked together on an in-depth project),
experts or novices (experienced dentists, trainees). The recom-
Concept maps
mended size for each focus group is usually 4–8 participants.
More than eight participants present audio-recording difficul- Concept maps are visual representations of the perceived link-
ties and reduce the air-time for each participant. It is better to ages between ideas, topics, procedures or arguments (49). The
have two or three smaller focus groups than one large one. The maps may be generated by individuals or groups and subse-
time allocation for a focus group is usually 1–1.5 h, depending quently refined. They may include brief notes to explain or
on the topic and the number of questions one uses. Sometimes describe the linkages between the concepts. Their structure is
it is useful to have two leaders, known as facilitators or moder- dependent upon the topic being explored and the depth of
ators, per focus group so that one can guide the discussion knowledge of the explorer. Concept maps can be used to com-
whilst the other observes and takes notes. pare the different constructions of a topic by traditional and
For a focus group to be successful, the researcher must be non-traditional students, experts and novices, to compare
able to stimulate interaction between the participants. Sugges- changes in knowledge from before and after an intervention, or
tions for structuring and facilitating a focus group are given in simply to ascertain the initial constructs of students entering a
(40) and (44). Essentially, these are the following: think care- course or going on a clinical placement (50–54).
fully about the opening, the key questions, your responses to There are plenty of computer programmes which supposedly
the discussion of the participants, the closing of the focus will produce concept maps or their near relations cognitive or
mind maps. For example, programmes can be downloaded
from http://cmap.ihmc.us/conceptmap.html to http://freemind.
sourceforge.net. But computer programmes can be constricting
and some training in generating mind maps is necessary for the
outcomes to be useful in research.

Qualitative data analysis and


presentation
Analysis of focus groups and interviews
The first step in data analysis of interviews and focus group
discussions is transcribing the data. One can transcribe merely
the words; the words, hesitations and stumbles (paralinguistic
cues); and the words, hesitations, stumbles plus indications of
non-verbal behaviour. Of these approaches, the second is usu-
ally preferable as one gains more meaning from the transcript.
A third category can be very time-consuming. It will require
Fig. 3. Differences between a Group Interview and a Focus Group. the assistance of an expert in video analysis and several

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Eur J Dent Educ 16 (2012) 110–117
Edmunds & Brown Doing qualitative research

viewings of the video-recordings. If you audio-record the inter- Produce a map of the themes and describe their relation-
view including hesitations and stumbles, then allow approxi- ships (note: in this case, a concept map is used to represent the
mately 5 · n (where n is the number of minutes of the outcomes of qualitative analysis rather than as a method of
interview or focus group) for the transcription by an experi- data generation).
enced typist. If you are using complex techniques of linguistics
or conversational analysis (12) for transcriptions of audio-
recordings, then allow at least 10 · n. If you video-record an
Writing for publication
interview to explore the non-verbal plus paralinguistic cues, Like all forms of good academic writing, writing qualitative
then allow at least 20 · n. research for publication is based on the principle of strong
The second step is to draw out the themes from the tran- alignment between the article’s title, abstract, introduction,
scripts or documents. A common method of doing this is to statement of research problem, a clear account of the methods
identify the tiny themes in the data, then group the tiny and results and a perceptive discussion of the findings.
themes into categories and then group the categories into However, the structure of a qualitative research paper is usu-
major and, perhaps, minor themes. This final categorisation ally less regimented than a quantitative one. First, the purpose
might include positive and negative aspects of a theme. This of the study is stated as an aim or research question, precise
method is referred to as thematic analysis or thematic content hypotheses are not given. In the Methods section, profiles of
analysis (55, 56), and it is commonly used in grounded theory participants are provided. If the sample size is small (<10),
research and in research which is not linked to a particular per- demographic and personal characteristics are sometimes given
spective. When the researcher uses a deliberately designed for each individual. Sample size (power) calculations are not
sequence of open questions, the process is sometimes known as required as qualitative research does not intend to generalise to
framework analysis (57, 58). In dental research, framework anal- a population. An overview of the interview schedule (list of
ysis is sometimes the most practical research method as com- questions asked) should be provided. Usually the themes cov-
pletely open interviews can be very time-consuming, and they ered in the interview/focus group are given along with one or
may not provide sufficient relevant information to the problem two example questions and their prompts/probes. The tran-
in hand. scription procedure is stated and the data analysis method
Computer-assisted qualitative data analysis (CAQDAS) pack- described. If one is writing for a qualitative journal with a
ages are available for analysing qualitative data. Online strong theoretical orientation, it is wise to discuss the theoreti-
resources are available at http://onlineqda.hud.ac.uk, and free cal perspective underlying the method of analysis used and the
CAQDAS package can be downloaded from http://www. rationale for its choice.
pressure.to/qda. The results and discussion in a qualitative paper are usually
However, CAQDAS packages have limitations, they can be more discursive and longer than in a quantitative study. The
cumbersome to use, and a computer-based approach is not results section begins with a brief account of the different levels
always sensitive to perspectives and nuances expressed in the of coding used and how these led to the identification of the
responses to open-ended questionnaires and interviews. For main themes. These themes may be merely listed. Some
small samples, it is easier to analyse by hand: reading, catego- researchers also report the frequency of themes mentioned by
rising, checking and re-categorising if necessary. Beware of participants. Or, as indicated earlier, connections between the
having too many categories or themes in the final analyses. themes can be shown in a diagram or mind map. Examples of
quotations or excerpts from interviews or focus groups are
often used to illustrate the themes. It is customary to anony-
Analysis of concept maps
mise these excerpts using either a participant code or pseud-
There is no standard method of analysing concept maps. But onyms. Other details which could identify an individual should
one can establish a set of criteria on which to judge a concept be omitted from direct quotations.
map. For example, one can match a participant’s concept map The discussion in a qualitative paper may be written as a
to a master template and assign a mark for the connections separate section following the results, or the results and discus-
(and explanations) or one can count the number of accurate, sion sections may be combined. By combining the sections, one
relevant nodes and strings (connections) in a concept map. avoids having to repeatedly describe the content of the themes;
however, a combined section can become long and rambling if
care is not taken with its structure. Check the layout of qualita-
Presentation
tive articles in the journal you hope to publish in before mak-
When the data have been analysed, one has a choice of how to ing a decision whether to write separate results and discussion
present the data. One can: sections or to combine them.
List the themes and give examples of quotations to illustrate Standard procedures of informed consent, confidentiality
the theme. These might include positive and negative and anonymity should be used and reported in qualitative
responses. research. Participants should be made aware of the broad con-
List the themes and count the number of times the theme is tent of any interview or discussion before agreeing to take part,
mentioned in the transcripts. and given the right to withdraw from the study at any time.
Produce a hierarchy or flowchart of the themes in the data Opinions and experiences described by participants in qualita-
and describe their relationships tive research may be very personal, and perhaps threatening to

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Doing qualitative research Edmunds & Brown

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