As surgeon scientists having undergone traditional training in research, we have been taught that quantitative data is the optimal way investigate healthcare phenomena. In clinical outcomes research there are more factors at play than what can be captured in the medical record or administrative database, however. There are social and cultural factors that influence patients’ and providers’ perceptions and actions that lead to observed clinical outcomes. Untangling these influences requires a social science research approach known as qualitative methods. In place of numerical data and statistical analysis, qualitative data utilizes information gathered from observation and interviews to formulate an understanding of why events occur in surgical settings. Qualitative methods can be used to generate hypotheses to test using traditional quantitative methods. This article will briefly review qualitative research in the health sciences, how it can aid in understanding trends in surgical outcomes, and what needs to happen to generate more of this essential data.
Brief Overview of Qualitative Methods
There are four common approaches to conducting qualitative research: phenomenology, discourse analysis, grounded theory, and ethnography.1,2 Phenomenology seeks to analyze lived experience by exposing assumptions that are taken for granted. Discourse analysis observes current in-use language to assess how individuals accomplish personal or social goals through language. By contrast, the grounded theory approach seeks to create a theory that will explain a social process by studying it within the environment it occurs. Finally, ethnography, or case study, is devised to understand the culture and practices of a group of people through observation or focus group discussions. The approach an investigator chooses should depend on what question they are attempting to answer. For example, if one was interested in understanding differences in nurse and physician management of hyperglycemia it would be best to select ethnography. But it the interest was in the interaction between nurses and physicians when a patient has hyperglycemia, discourse analysis would be more appropriate.
How Qualitative Data Can Be Used in Surgery
The role of qualitative research is to answer questions that statistical analysis cannot answer and to generate hypotheses for future investigation. There are a great many areas where these approaches could be applied to improve the delivery of surgical care. One area primed for surgical qualitative investigation is quality improvement. Systems and communications failures have been linked to in-hospital medication errors.3,4 Understanding why these failures occur is key to improving delivery of care. By observing physicians, nurses, and pharmacists going about their daily routines and witnessing their interactions, areas for improvement will likely become evident. This information can then be used to create an intervention to improve patient care.
Another area amenable to qualitative research in surgery is the field of outcome disparities. There is a wealth of data across a variety of surgical specialties that patient outcomes are affected by patient race, gender, insurance status, and socioeconomic status.5-7 Over the years, many assumptions have been made as to why certain groups have worse outcomes than others, ranging from provider implicit bias to limited healthcare access. Qualitative analysis of patient and provider experiences before, during, and after delivery of their surgical care has the potential to illuminate possible ways to improve access to patients or provide more resources post-operatively in order to ensure equitable outcomes for everyone.
Areas for Growth in Surgical Qualitative Research
As one might imagine, gathering qualitative data can be extremely time-consuming. Collecting observational or interview data to the point of saturation can take months. Not to mention that coding and analyzing the collected data is often iterative, again requiring a significant amount of time. In order for a surgeon to complete a project using this methodology, they will require support from their department and expertise from other groups with qualitative methodology experience such as epidemiologists. Having avenues to obtain funding to pursue these methods is necessary. In addition, there is evidence that only 8% of surgical qualitative studies have been published in surgical journals since 1983 with the majority being published in nursing journals.8 The inability to publish such time-consuming work where colleagues will view it is a deterrent to pursuing this line of investigation for many researchers. Surgical journals will need to invest in reviewers and editors with experience in qualitative methods to ensure that high-quality qualitative research is published where surgeons can view them and begin generating hypotheses of their own.
- Starks H, Trinidad SB. Choose Your Method: A Comparison of Phenomenology, Discourse Analysis, and Grounded Theory. Qual Health Res 2007; 17: 1372-1380.
- Vaismoradi M, Turunen H, Bondas T. Content Analysis and Thematic Analysis: Implications for Conducting a Qualitative Descriptive Study. Nurs Health Sci 2013; 15: 398-405.
- Kuitunen S, Niittynen I, Airaksinen M, Holmstrom AR. Systemic Causes of In-Hospital Intravenous Medications Errors: A Systematic Review. J Patient Saf 2021; 17: e1660-e1668.
- Manias E, Cranswick N, Newall F, Rosenfeld E, Weiner C, Williams A, Wong ICK, Borrott N, Lai J, Kinney S. Medication Error Trends and Effects of Person-Related, Environment-Related and Communication-Related Factors on Medication Errors in a Paediatric Hospital. J Paediatr Child Health 2019; 55: 320-326.
- Freeman J, Boomer L, Fursevich D, Feliz A. Ethnicity and Insurance Status Affect Health Disparities in Patients with Gallstone Disease. J Surg Res 2012; 175: 1-5.
- Bailey KS, Marsh W, Daughtery L, Hobbs G, Borgstrom D. Gender Disparities in the Presentation of Gallbladder Disease. Am Surg 2019; 85(8): 830-833.
- Buscaglia JM, Kapoor S, Jagannath SB, Krishnamurty DM, Shin EJ, Okolo PI. Disparities in Demographics Among Patients with Pancreatitis-Related Mortality. J Pancreas 2009; 10(2): 174-180.
- Maragh-Bass AC, Appelson JR, Changoor NR, Davis WA, Haider AH, Morris MA. Prioritizing Qualitative Research in Surgery: A Synthesis and Analysis of Publication Trends. Surgery 2016; 160(6): 1447-1455.