Qualitative Research Part 1: Understanding Its Place in Mental Health Nursing Practice

Abstract

Qualitative research methods complement mental health nursing practice—with a focus on the lived experience. These methods do not work from pre-determined categories applied to the person's experience but rather seek to find and interpret the categories and themes from within the collected data Qualitative research fits with the skills embedded in mental health nursing practice, qualitative research because it is well-suited to the investigation of the complexities of human responses and experiences that are integral to everyday practice. Mental health nurses who practice a recovery-focused model of care have a unique perspective on the complexities of mental health distress and the patient's needs for connectedness, hope, identity, meaning and empowerment that promotes recovery (Leamy et al. 2011).

Qualitative research methods are oriented towards understanding meanings and experiences. They are therefore potentially very useful in the mental health context because they can provide new insights and knowledge in poorly understood and complex areas, such as understanding subjective experiences of mental disorders and their treatments (Fossey et al. 2002). The subjective experience is needed to inform the interpersonal, socio-cultural and political context of mental distress, treatment and service delivery. While quantitative and statistical research methods enable deduction and prediction irrespective of context, qualitative research enables contextualised understandings of subjective experiences.

Quantitative research is focused on the experimental examination of an intervention in terms of quantity, amount, intensity or frequency and is supposedly objective but the choice of what is examined and how is always a subjective process. Qualitative researchers study things in their natural setting, attempting to make sense of or interpret phenomena in terms of the meanings people bring to them (Denzin and Lincoln 2011). It does not obscure the subjective nature of the research process but acknowledges that there can be multiple interpretations of the data. An audit trail identifies how the interpretations were developed.

While qualitative research makes no claims to objectivity it does follow rigorous processes based on theoretical paradigms and epistemologies. These need to be clearly stated within the paper because they determine the characteristics of the study aim and its methods of data collection and analysis. The most commonly used methods are phenomenology, grounded theory, discourse analysis and interpretative thematic analysis. These methods are supported by explicit theoretical paradigms underpinned by ontological and epistemological assumptions of the nature of reality and the nature of experience.

The following section provides an overview of some of the core methodologies. This is not an exhaustive list but reflects the papers submitted to this Journal.

A phenomenological approach to qualitative research is concerned primarily with lived experience. It is underpinned by phenomenological philosophy and is focused on the investigation and description of phenomena as consciously experienced. There are different kinds of phenomenology, each rooted in different ways of conceiving the what and how of human experience. In other words, each approach of phenomenology is rooted in different schools of philosophy. The two main schools are the hermeneutic (interpretive) (Heidegger 1962) and the transcendental (descriptive) (Husserl 1963).

Undertaking phenomenological research requires a deep understanding of phenomenological philosophy and several authors have described methods that provide a way of conducting the research. For example, Van Manen (1990) outlines an approach that involves (1) Turning to the nature of lived experience (formulating the research question), (2) Investigating experience as we live it (conducting interviews from a phenomenological perspective), (3) Reflecting on the essential themes that characterise the phenomena (data analysis focussing on lived time, lived space, lived relations and lived body), (4) Describing the phenomena in terms of phenomenological themes, (5) Maintaining a strong and oriented relationship with the phenomena, (6) Balancing the research context by considering the parts and the whole. Phenomenological research needs to stay true to its philosophical roots and is a method that needs to be followed meticulously. Examples of the use of phenomenology in mental health nursing include the exploration of nurses' lived experiences of participating in physical restraint (Bigwood and Crowe 2008), family dynamics in dementia care (Smith, Morton, and van Rooyen 2022) and collaboration between the mobile crisis unit and police (Daggenvoorde et al. 2022).

Grounded theory is a systematic and structured qualitative methodological approach that aims to develop theory from the data. It is another methodology underpinned by philosophical positions and was initially developed by Glaser and Strauss (1967). The research process is driven by the philosophical underpinnings.

The grounded theory method involves theoretical sampling (recruiting a purposive sample related to the area of interest), generating data via interviews and observations, concurrent data collection and analysis, constant comparative analysis, initial coding (open coding), axial coding (relationships between codes), selective coding (identification of a core category) and development of a theory of the conditions associated with the core category. The theory is developed through this process of inductive reasoning. It can be regarded as a process of hypothesis generation grounded in the data.

A distinguishing feature of grounded theory is that there is no pre-research literature review. The literature is integrated into the process based on the developing codes. When codes are identified the researcher turns to the literature as another form of data collection. The literature is used alongside the data collected by interviews. Another distinguishing feature is that data collection and data analysis are concurrent. Each interview is analysed as it is collected and this determines the subsequent interview questions. Examples of the use of grounded theory in mental health nursing practice include a study of how community mental health nurses derive job satisfaction (Wilson and Crowe 2008), patients' experiences of discharge (Keogh, Callaghan, and Higgins 2015) and coping processes for people with schizophrenia (Jacques, St-Cyr Tribble, and Bonin 2019).

Discourse analysis is concerned with how an individual's experience is socially and historically constructed by language. This is a significant ontological shift from other qualitative methods in that it recognises the socially constructed nature of reality as opposed to the individual experience of reality. It places the social and historical context, rather than either the researcher's hypotheses or the individual's experience, as central to the inquiry process. It takes a theoretical position that subjectivity and experience are constructed by language and are, therefore, discursively constituted. A distinction from other methodologies is that the context in which discourse and discursive practices (activities produced by discourses) occur is central to the research process (Crowe 2005).

Discourse analysis assumes that language constructs how we think about and experience ourselves and our relationships with others. That language is always embedded in a particular discourse. Fairclough (1992) outlined three ways in which the constructive effects of discourse are evident: they contribute to the construction of subject positions (ways of being in the world); they construct social relationships between people; and they contribute to the construction of systems of knowledge and belief. Parker (1999) described how words and phrases do not come already packaged with a specific delimited meaning that a researcher can be sure of, as if they were fixed or contained. It is the interweaving of words and phrases in different contexts that gives them their sense, and when we attempt to grasp patterns in a text we have to carry out that exercise against a cultural backdrop.

A range of discourses such as medical, recovery and psychological discourses has influenced how mental health nursing is practised. The most dominant discourse that influences not only mental health nursing practice but also the experiences of those who come into contact with them, is psychiatric discourse (Crowe 2022). Other discourses also influence mental health nursing practice, for example, neo-liberalism, managerialism and recovery but psychiatric discourse has the most authority.

The process of discourse analysis involves first selecting a research question that may relate to a written text and/or interviews that are transcribed into texts. The chosen text must be acknowledged as strongly influential in the practice setting and interviews are analysed to identify the discourses that the participants draw upon in their speech and descriptions. Several epistemological paradigms can underpin discourse analysis, for example, Foucauldian, Lacanian, but perhaps the most common is critical discourse analysis. Fairclough (1995) has described critical discourse analysis as based on the premise that texts have a constructive effect in shaping how we experience ourselves and others and how we enact this.

The process of analysis involves identifying the specific purpose of the text (what the text itself says about its purpose), the processes the texts use for claiming authority, its connections with other texts and discourses, how the text influences and is influenced by media, how the major concepts are constructed, the processes used for naming and classifying, how subject positions are constructed (what ways of being are authorised) and construction of reality and social relations. This is in-depth work that relies on an understanding of how power relations operate in our society. It is a methodology well-suited to mental health nursing practice and can be used to explore how normality and mental disorders are constructed in our society (Crowe 2000), how personality disorders are constructed (Crowe 2008), risk assessment (Crowe and Carlyle 2003) and recovery (Crowe 2022).

The process of TA has been described by Braun and Clarke (2006) as a theoretically flexible method that organises, describes and interprets qualitative data. It is a method for identifying, analysing and reporting patterns (themes) within data. Thematic analysis is more than a method to analyse data but has a stated epistemological or theoretical position. It goes beyond the latent level of the data to identify or examine the underlying ideas, assumptions, conceptualisations and ideologies that are theorised as shaping or informing the semantic content of the data (Braun and Clarke 2006, 84).

While all transcript data are required to develop the themes, it is not necessary to use all the data to illustrate each theme. The quotes used need to be those that capture discrete aspects of the theme.

Thematic analysis can be a method that works both to reflect reality and to unpick or unravel the surface of ‘reality’. However, the theoretical position of thematic analysis must be made clear, as this is all too often left unspoken (Braun and Clarke 2006). It can be conducted within both realist/essentialist and constructionist paradigms or somewhere in between, although the outcome and focus will be different for each. Examples of thematic analysis in mental health nursing research include interviews with patients about how they are functioning (Crowe et al. 2021) and the impact of having a bipolar disorder diagnosis (Crowe et al. 2012).

A summary of the key features is provided in Table 1. The table presents a fairly simplistic overview of each methodology and is by no means extensive nor does it engage with the ongoing debates and developments within each.

In quantitative research, the standards of rigour are determined by evaluations of validity and reliability. However, in qualitative research, no attempt is made to generalise the findings and it is openly recognised as an interpretive process. The same data could be interpreted in different ways, so it is important to have clear descriptions of how rigour was maintained in the research process. The hallmarks of qualitative rigour have been described by Koch (2006): as credibility, transferability and dependability. Credibility describes how the analysis was undertaken and by whom. Transferability refers to sufficient detail of context provided to enable the reader to assess similarities to their practice area. Dependability involves the description of the interview questions, and the rationale for these in terms of the overall research question, and the process of coding and theme development is clearly described, with sub-themes and codes provided within each theme to enable readers to follow the process of development.

Qualitative research is congruent with the focus of mental health nursing. It provides insights into patients' experiences and perceptions that may elude quantitative approachesl The choice of methodology is often established by the research question; however, subjective choice also plays a role. Most methodologies involve a form of thematic analysis, but the method for conducting the analysis is determined by the method. The next paper in this series will explore the process of developing a research question, collecting data and data analysis.

The authors declare no conflicts of interest.