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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Review
Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review Rachel Anne Kornhaber a,b,c,*, A.E.E. de Jong d,e, L. McLean f,g,h a
University of Tasmania, Faculty of Health, School of Health Sciences, Australia The University of Adelaide, School of Nursing, South Australia, Australia c Severe Burns Injury Unit, Royal North Shore Hospital, Sydney, NSW, Australia d Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands e Association of Dutch Burn Centres, Beverwijk, The Netherlands f Westmead Psychotherapy Program, Discipline of Psychiatry, and BMRI, Sydney Medical School, University of Sydney, Australia g Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia h Sydney West and Greater Southern Psychiatry Training Network, Australia b
article info
abstract
Article history:
Qualitative methods are progressively being implemented by researchers for exploration
Received 4 December 2014
within healthcare. However, there has been a longstanding and wide-ranging debate
Accepted 17 April 2015
concerning the relative merits of qualitative research within the health care literature.
Available online xxx
This integrative review aimed to exam the contribution of qualitative research in burns care
Keywords:
using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature
and subsequent rehabilitation. Studies were identified using an electronic search strategy Qualitative research
(CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary
Burns
research in English between 2009 to April 2014 using Whittemore and Knafl’s integrative
Nursing
review method as a guide for analysis. From the 298 papers identified, 26 research papers
Integrative review
met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6–53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research. # 2015 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Locked Bag 5052, Alexandria, NSW 2015, Australia. Tel.: +61 2 85727969. E-mail address: [email protected] (R.A. Kornhaber). http://dx.doi.org/10.1016/j.burns.2015.04.007 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Contents 1. 2.
3.
4.
5.
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Data reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. In which domains has qualitative research been used in burns research? . . . . . . . . 3.2. Why has qualitative research been used in burns research? . . . . . . . . . . . . . . . . . . . 3.3. How has qualitative research been used in burns research? . . . . . . . . . . . . . . . . . . . 3.4. How and where has qualitative research in burns been reported in the literature? . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Criteria for evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Limitations and strength of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Qualitative methods are progressively being implemented by researchers to explore aspects of healthcare that are untapped by quantitative methodologies [1]. Researchers have been utilising qualitative research methodologies since the 1960s [2]. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature [3]. Despite qualitative research becoming more prominent in medicine and healthcare literature, it is a commonly held belief that qualitative research can only address limited research questions and therefore merely complement empirical approaches [4,5]. This may be due to researchers being well versed in quantitative research and unfamiliar with qualitative research and its central tenets. Therefore it is essential to convey that the unique position of the qualitative researcher is to ‘understand, explain, and demystify social reality through the eyes of different participants’ [6]. Quantitative research is objective in its approach and therefore aims to provide an overarching and often linear and normographic explanation rather than develop a deeper ideographic and complex understanding. Dingwall et al. [7] argue that qualitative research has a fundamental role in: addressing the gap between the filigndings of [randomised controlled trials]. . . and the practice of decision-making in individual cases with individual patients. The more individualised an intervention becomes, the greater the role that qualitative work is likely to play in its evaluation. Qualitative research has come under intense scrutiny and, at times, received harsh criticism from those in the medical profession [8]. Primarily utilised by those in nursing and the social sciences, qualitative research is a broad term for a diversity of methodological approaches. Qualitative methodologies allow the researcher to: challenge assumptions about
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health and illness; contribute to the development of theory for practice; offer a way to change how issues are conceptualised and enable one to see the world from another’s point of view that focuses on meaning, interpretation and understanding. Creswell [9] states that: ‘Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex, holistic picture, analyses words, reports detailed views of informants, and conducts the study in a natural setting.’ The proliferation of qualitative research over the past decades has advanced health science, in particular nursing and the social sciences, contributing to the collective understanding of the experiences of health and illness. In recent years, qualitative research has gained considerable momentum with a noticeable shift towards the use of qualitative research methodologies that is evident in the number of qualitative peer reviewed publications globally. This trend is clearly noted over the last decade within the burns literature. A scoping search of burns research found that since 1998, there have been less than 100 published qualitative peer reviewed research papers exploring burn injury however over 40 of these have been published since 2009 alone. Among them, phenomenology, ethnography, grounded-theory, social constructionism and action research were methodologies utilised to explore and emphasise critical issues in burn care. Consequently, the utility of qualitative research as a rigorous, robust and systematic approach for health professionals investigating burns trauma warrants further exploration. Increasing complexity in burn care, combined with the rising trajectory of qualitative methodologies in burns research, supports the need for a current examination of the contribution to qualitative research in burns care and rehabilitation. Therefore, the aim of this study is to critically appraise the use of qualitative research in the field of burn management and rehabilitation.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
JBUR-4627; No. of Pages 8 burns xxx (2015) xxx–xxx
3
2.
Methods
focus across nursing, medicine and allied health related research literature.
2.1.
Review process
2.3.
Inclusion criteria
Integrative reviews are broader in the description and understanding of an area of research compared to a systematic review that addresses a specific clinical question [10,11]. An integrative review therefore has the potential to build knowledge presenting various perspectives on the phenomenon of interest [12]. Consequently the framework guiding this integrative review is based on Whittemore and Knafl’s [12] five stages: problem identification, literature search, data evaluation, data analysis and presentation (Fig. 1).
The search criteria for this integrative review incorporated peer reviewed reports of original qualitative research published in the English language within the last 5 years that described the management of burns including prevention, treatment, rehabilitation and psychosocial implications. As there has been a notable increase of qualitative methodological papers in the field of burns care, the 5-year range between 2009 to April 2014 was implemented to create a manageable sample for analysis. Abstract, conference proceedings, theses and editorials were excluded as were secondary sources and reviews.
2.2.
2.4.
Literature search
A systematic search was conducted of PubMed, CINAHL, EMBASE and SCOPUS database. Importantly, CINAHL was utilised as it is well known to use index terms that encapsulate qualitative research methodology [13]. Boolean connectors AND, OR and NOT were used to combine search terms as qualitative research, phenomenolog*, grounded theory, ethnograph*, action research and burn*. The aforementioned databases were chosen because they reflect a comprehensive
Data extraction
Two of the authors (R.K. and A.d.J.) independently appraised the data from each study and any disagreements were resolved by consensus discussion. This was conducted using the Joanna Briggs Qualitative Assessment and Review Instrument (QARI) Critical Appraisal Checklist for Interpretive and Critical Research. A total of 34 papers were reviewed of which 8 papers were excluded because they did not meet the inclusion criteria. On completion of the full review, 26 papers met the final criteria for inclusion (see Fig. 1).
2.5.
Data synthesis
The data analysis commenced with a narrative evaluation of the study’s characteristics. As there are various complexities that exist whilst evaluating primary sources of data when conducting an integrative review, analysis may become exceedingly complex. In addition, combining different research methodologies and data poses inherent risks that can lead to a lack of rigour, inaccuracies and bias [12]. Therefore our sample included primary sources of qualitative methodologies. Papers shown in Table 1 were converted from individual sources into a manner that assembles the data from multiple primary sources about particular variables or subgroups [12].
2.6.
Fig. 1 – Flow diagram of integrative review.
Data reduction
Whittemore and Knafl [12] recommend data reduction in accordance with ‘specific issues, variables or study characteristics. Of the 26 papers included, there was an average of 22 participants involved in each study with a range of 6–53 participants conducted across 12 different nations (see Table 1). Among the studies reported five key domains were identified: burns prevention, paediatric burns/parenting, appropriate acquisition and delivery of burns care, pain and psychosocial implications including concerning return to work, peer support, quality of life and coping and adapting. The methodologies utilised included narrative/thematic/content analysis, phenomenology, ethnography, grounded theory and social constructionism. Papers were cited on average seven times with a range from 0 to 22 with the more recent publications having no or few citations.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Table 1 – Integrative review sample by burn care context. Context Authors and origin
3.
Burns prevention
Paediatric burns/parenting
Deliver of care
Pain Yuxiang et al. [18], China Tengvall et al. [35], Sweden
Psychosocial
Durand et al. [15], UK
Ravindran et al. [40], India
Norouzi et al. [25], Iran
Van Niekerk et al. [16], South Africa Mashreky et al. [39], Bangladesh
Ravindran et al. [41], India
Abu-Qamar and Wilson [37], Jordan
Horridge et al. [20], UK
Abu-Qamar and Wilson [36], Jordan
Kornhaber et al. [22], Australia
McGarry et al. [14], Australia McGarry et al. [24], Australia
Dahl et al. [31], Sweden Badger and Royse [38], USA Sadeghi Bazargani et al. [17], Iran
Moi and Gjengedal [32], Norway Oster et al. [33], Sweden
Results
Findings were compiled to reflect the utility, rigour and credibility of the qualitative research framed by the following questions: (1) In which domains has qualitative research been used in burns research? (2) Why has qualitative research been used in burns research? (3) How has qualitative research been used in burns research? (4) How and where has qualitative research in burns been reported in the literature? Table 2 demonstrates the potential for qualitative to inform practice and improve outcomes in relation to burns prevention, delivery of burn care and rehabilitation of burn survivors.
3.1. In which domains has qualitative research been used in burns research? Qualitative research methodologies were utilised to explore experiences and phenomena of burn survivors and their families across the age continuum, e.g. [14,15] and in a cross section of burns management contexts including prevention, e.g. [16], pre-hospital management, e.g. [17], acute care, e.g. [18], rehabilitation, e.g. [19] and returning to work/school, e.g. [20,21]. Furthermore, qualitative methodologies were frequently implemented to explore psychosocial aspects of burns trauma, e.g. [22]. It is interesting but not surprising to note, that over half of studies identified were from a nursing origin as nursing aims to gather an in-depth insight and understanding of human behaviour, attitudes, values and beliefs, goals and culture perspectives as important aspects of nursing care. Furthermore, a qualitative methodology best addresses these aspects when exploring human nature. Papers from an allied health perspective have also featured in this review. Medical authors and co-authors are underrepresented and may reflect that academic medicine has not yet discovered the power of a qualitative or mixed methods approach.
Rossi et al. [27], Brazil
Badger and Royse [30], USA
Lau and van Niekerk [23], South Africa Mackey et al. [21], UK Ciofi-Silva et al. [19], Brazil Zhai et al. [29], China Rahzani et al. [34], Iran
3.2. Why has qualitative research been used in burns research? Each of the studies’ aims and objectives were reviewed for the terminology utilised. It was identified that verbs/verb phrases were used to describe the purpose including elaborate, illuminate, examine, describe, explore, discover and gain an indepth understanding. These verbs and phrases resonate with a qualitative approach in order to obtain a rich understanding of the core issues or processes burn survivors or their carers experienced so as to construct a thick description and a comprehensive account of the phenomenon. Quantitative research often relies on grouped data that averages scores to reduce variability and ‘simplify’ or ‘thin’ the picture. It often maps the spread of data with reference to means and standard deviations, using probability theory to develop specific hypothesis testing around differences between groups or differences over time. Qualitative research alternatively openly captures and explores the complexities and the depth of experiences and as such can be used to construct broader theory [4], for the exploration of ‘personal, social, cultural, spiritual, and other meanings and constructions’, and the detailed explorations of processes, tasks for which quantitative approaches can be less suited [23]. Consequently, qualitative methodologies were therefore primarily used to describe, illuminate and explore phenomena of interest to the field of burns. When the papers were examined for justifications to align method with the aims of the study authors offered rationales that related to the above notion of a detailed examination of complex phenomena. For example, in the area of burns prevention, McGarry et al. [24] used a phenomenological methodology (which provides greater insight into understanding human experiences with perception being pivotal to experiences) to describe the ‘lived experience’ of parents of children admitted to hospital for a burn and fundamentally sought to understand the essence of the individuals’ experiences. Norouzi et al. [25] used grounded theory to generate
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Table 2 – Thematic analysis of burn care research domains. Context
Burns prevention
Paediatric burns/ parenting
Deliver of care
Pain
Psychosocial
Those seeking to introduce engineering-based scald prevention interventions in social housing need to emphasise potential environmental and financial impacts of water temperature reduction and the benefits of promoting safety for vulnerable populations. Safety education programmes are reported to be an effective intervention in improving knowledge and practices of rural people in lower income countries with regard to prevention of burns injuries in paediatric populations. Although implementation of these programmes in low income settings are problematic.
Childhood burns were reported to be painful and traumatic for both the child and parents. Confidence along with role adaptation, acceptance was pivotal in the return to school process. Culture of blame was encountered among parents. Parents endured the process of blame. Parents will benefit from ongoing assessment and psychological interventions that will provide emotional support. Parents in turn perceived minimal support from health professionals and family members. Stressors, behavioural and emotional responses and coping factors were commonly reported. Further support for parents and their burned children would complement and support the existing surgical and medical treatment plan, providing direction for comprehensive service delivery and improved psychosocial outcomes in children.
Unintegrated care emerges as a fundamental issue for burn survivors. Burn survivors require adequate reinforced education about the plan for their burn care, the physiological changes, more involvement and social support to cope with the traumatic event. Culturally specific health education programmes should be made to raise patients’ awareness towards avoiding possible burn risks. Inappropriate perceptions regarding initial management of burns existed. Respect, communication and provision of competent care were identified as fundamental elements in delivering competent burn care.
Pain was a fundamental issue in the treatment of burn injury and often reported as undertreated. Adequate pain management facilitated boosting self-confidence and inner strength. Freedom from pain was noted to be an unrealistic notion as burn survivors endured the experience of pain mostly alone. A multidisciplinary approach in the treatment of pain is fundamental in the rehabilitation of burn survivors.
Burn survivors struggled with their injury and how they perceived life after rehabilitation with implications for quality of life, adapting and coping. Findings revealed positive insight concerning the value of social and peer support in providing a sense of belonging, hope, resilience and facilitated with acceptance, coping strategies and greater selfawareness and personal growth. Goal setting enabled return to work/ school and an improved quality of life. However, pain, limited knowledge, lack of individualised rehabilitative care and psychosocial support inhibited return to work and activities of daily living. Understanding these concepts through the burn survivors’ perspective has the ability to facilitate a better understanding of how to best navigate psychological adjustment, return to work/school and social reintegration. These collective results show the importance of the sociocultural dimension in the concept of quality of life for persons undergoing burn rehabilitation. The use of structured educational programmes and organising peer support has significance for support from family, friends and health professionals.
Findings
theories regarding social phenomena and develop higher level understanding that is ‘grounded’ in, or derived from, a systematic analysis of data [26] concerning the rehabilitation care process in patients who were burn-injured as a result of self-immolation. Rossi et al. [27] employed an ethnographic design exploring social interactions, behaviours, and perceptions that occur to illuminate the cultural meaning and dimensions of quality of life from the perspective of Brazilian burn patients. Lau and van Niekerk’s [23] research was informed by social constructionism, which is primarily concerned with illuminating the process by which individuals come to describe or explain the world in
which they reside and attempt to express common forms of understanding that have been socially negotiated [28]. Zhai et al. [29] utilised a qualitative approach to explore whether the phenomenon of post-traumatic growth would be found in a Chinese sample to substantiate that the phenomenon was cross cultural and that the dimensions tapped by a previously developed questionnaire score, the Posttraumatic Growth Inventory, adequately tapped the Chinese mainland experience. In this example the qualitative approach was used to explore whether the quantitative method developed in another cultural context had construct validity in the new context.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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3.3. How has qualitative research been used in burns research? Qualitative research can access information via a number of routes: interviews of individuals, members of families/ systems or focus groups, where the participants have a direct voice; observations of participants (often as field notes) where action and interactions are described by the researcher; detailed examination and analysis of artefacts: art, music, texts, such as diaries. In the papers selected the overwhelming majority of papers used semi-structured interviews of individuals [16,18,20– 24,30–35] and two studies used unstructured interviews [36,37]. In one study the nature of the interview as structured or unstructured was not clarified [15]. Other studies used focus groups as the interview approach [17,38,39]. One study used a mix of interviews and a reflective diary [29]; three others used a mix of interviews and observation [27,40,41]. One used a combination of all three qualitative approaches [25] and one study used a modest combination of qualitative and quantitative methods [19]. The above spread of approaches, clustered around the semi-structured individual interview might suggest that the qualitative methodologies are still new in burns research, emphasising the qualitative experience of small research teams and groups. The potential for mixed methods approaches, which require collaborations between quantitative and qualitative approaches, and often allow a multidisciplinary or inter-disciplinary approach is as yet untapped.
3.4. How and where has qualitative research in burns been reported in the literature? The publications selected encompassed a broad area of burn care ranging from prevention to rehabilitation and the long term psychosocial implications from a multiplicity of settings and cultural backgrounds. Qualitative research publications in the area of burn management and rehabilitation were published across several disciples including nursing [18,19,25,27,29,31–36,40,41], social work [23,30,38], occupational therapy [14,24], public health [15,16], medicine/surgery [21], psychology [20], epidemiology [16,17,39] and rehabilitation [19,22] demonstrating a wide and diverse scope. Of significance was the large percentage of papers published in peer reviewed journals with an impact factor including the Journal of Clinical Nursing [25,32], Burns: Journal of the International Society for Burn Injuries [14,15,17,18,20–22,34,40], International Journal of Nursing Studies [41], Journal of Burn Care and Research [31,35,38] and Public Health [16,39]. Papers published in peer reviewed journals denote research of high quality, with methodological rigour that is judged and valued by peers. Therefore rigorous, robust and systematic qualitative publications in peer reviewed journals supports and facilitates the use of qualitative methodologies in burn care and rehabilitation. Based on the breadth and depth of peer reviewed publications cited in this integrative review, it is evident that qualitative research in the period has explored critical issues in burn care and contributed to the expanding body of burns knowledge and is now placed alongside the quantitative burns literature. It is likely that it will continue to be a visible
presence in mainstream burns research. Perhaps the fundamental value and utility of qualitative research methodologies is beginning to be realised.
4.
Discussion
The purpose of this critical assessment was to critically appraise the use of qualitative research in the field of burn management and rehabilitation. The following discussion will encompass the criteria for evaluation and the limitations and strength of evidence of this integrative review.
4.1.
Criteria for evaluation
Statements locating the research within a sociocultural framework [15–17,19–21,29,30,36,37,39–41] were common in the papers identified and speaks to a strength of qualitative approaches. Fewer papers clearly identified a theoretical perspective [18,23,27,29,32,34,38]. Investigators are an integral part of the research process [3]. Hence, Bailey et al. [42] states that the broader application of qualitative research in healthcare has been accompanied by a resounding concern to establish what actually represents and comprises methodologically rigorous qualitative research. As a result, qualitative research is at risk of criticism with claims that it is subjective and anecdotal, prone to researcher bias (conscious or unconscious) [4]. Furthermore, tension remains around qualitative research methodologies from social sciences and building evidence from practice [43]. Practices as triangulation are reported to address the issue of internal validity by the use of more than one method of data collection in order to answer the research question, check and establish validity in their studies by analysing a research question from multiple perspectives. Where appropriate, member checking whereby key themes and findings are returned to the participants to attain congruence between both the researcher and participants’ perceptions are key aspect in the establishment of credibility [44] and enables the participant the opportunity to validate their transcripts and the interpretations of the findings [45]. Lincoln and Guba [44] postulate that this is a critical technique for establishing credibility however, member checking remains highly controversial among qualitative researchers reflecting diversity in criteria to rigour depending on the question being posed [46,47]. Multiple coding which is likened to inter-rater reliability within quantitative research, where possible, can further reduce researcher bias and strengthen the study’s credibility and rigour and was used in several of the studies selected. Multiple coding involves two or more researchers analysing the same data transcripts and comparing and contrasting their findings. However, when revisiting data, interpretations of their data may shift over time [48]. Furthermore, given the complexity of qualitative data and the diverse background and scope of researchers, there are variations in the approach taken to code frameworks, in particular the language utilised [49]. Depending on the methodological framework, concepts such as bracketing utilised in descriptive phenomenology inquiry require the researcher to consider preconceptions, biases and assumptions related to the phenomenon prior to
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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and throughout the study [50] in order to reduce the likelihood of misinterpretation and contamination of the raw data. However, uncontaminated data makes it difficult to test findings using qualitative methods. Within some schools there is room/scope for qualitative researchers to develop this aspect of practice. Lastly, it is also imperative to account for negative cases which oppose the developing explanations. Examples such as these methods described are necessary to implement where appropriate, so as to attain a robust, rigorous and systematic approach to qualitative research. However, it is interesting to note that Barbour [51] suggests that the use of these strategies does not in itself, confer rigour as a broad understanding of qualitative research design and data analysis is necessary and only then can these strategies strengthen the rigour of qualitative research.
4.2.
7
address the phenomena of burn management in its complexities. Although some still regard qualitative methods as fundamentally inferior to the previously mainstream quantitative approaches, it is to be hoped that health professionals and researchers, including medical professionals become familiar with the richness and scope afforded by qualitative and mixed methods research in burns. This is especially pertinent now, where there is currently a changing health climate which demands an increasingly greater evidence-base alongside patient and carer participation, and the rigorous assessment and evaluation of outcomes and services via methods that respect the individual and their cultural context and preserve aspects of process and lived experience.
Conflict of interest
Limitations and strength of evidence The authors declare that they have no conflict of interests.
Despite the review identifying that a majority of the selected studies did report the use of appropriate methods to demonstrate rigour, credibility and trustworthiness, a lack of philosophical detail underpinning the studies was evident with only a few papers addressing the philosophical, conceptual or theoretical background of the methodology. For example, confusion seems to remain surrounding the concept of sample size which is a redundant concept within qualitative research. It is the notion of data saturation that is a key element in qualitative methodologies: the point at which data collection ceases as no new information is forthcoming [52]. The resultant data are quality driven not sample size dependent. Without data saturation qualitative research lacks rigour and may be deemed invalid. In some cases, there may only be a few people eligible to be involved in the research because of the uniqueness of the investigation.
5.
Conclusion
Qualitative research has the ability to capture the perspectives and experiences of those involved in the phenomenon of burn injury and rehabilitation and to contribute to the emerging body of knowledge and research on the process of rehabilitation. This has the capacity to improve patient outcomes, care practices and to influence health policy in the local, national and international arenas. Given the psychosocial aspects of burn management, qualitative research methodologies are a prime approach to explore burn survivors’ unique experiences in a rigorous, robust and systematic manner. Both qualitative and quantitative research continues to coexist within burns literature as both paradigms have been acknowledged to inform clinical practice and resulted in improved outcomes. However, controversy has remained till recently around whether qualitative research can address clinical and biopsychosocial research questions. In many cases, quantitative research is the most appropriate method to answer questions posed in healthcare. However, qualitative research is deemed fit to tackle innovative questions arising out of contemporary health care. Intrinsically, qualitative methodologies are well entrenched in nursing research and have more recently shown themselves to be well-accepted methodological approaches to
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Review
Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review Rachel Anne Kornhaber a,b,c,*, A.E.E. de Jong d,e, L. McLean f,g,h a
University of Tasmania, Faculty of Health, School of Health Sciences, Australia The University of Adelaide, School of Nursing, South Australia, Australia c Severe Burns Injury Unit, Royal North Shore Hospital, Sydney, NSW, Australia d Burn Centre, Red Cross Hospital, Beverwijk, The Netherlands e Association of Dutch Burn Centres, Beverwijk, The Netherlands f Westmead Psychotherapy Program, Discipline of Psychiatry, and BMRI, Sydney Medical School, University of Sydney, Australia g Consultation-Liaison Psychiatry, Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia h Sydney West and Greater Southern Psychiatry Training Network, Australia b
article info
abstract
Article history:
Qualitative methods are progressively being implemented by researchers for exploration
Received 4 December 2014
within healthcare. However, there has been a longstanding and wide-ranging debate
Accepted 17 April 2015
concerning the relative merits of qualitative research within the health care literature.
Available online xxx
This integrative review aimed to exam the contribution of qualitative research in burns care
Keywords:
using the databases PubMed, Cumulative Index of Nursing and Allied Health Literature
and subsequent rehabilitation. Studies were identified using an electronic search strategy Qualitative research
(CINAHL), Excerpta Medica database (EMBASE) and Scopus of peer reviewed primary
Burns
research in English between 2009 to April 2014 using Whittemore and Knafl’s integrative
Nursing
review method as a guide for analysis. From the 298 papers identified, 26 research papers
Integrative review
met the inclusion criteria. Across all studies there was an average of 22 participants involved in each study with a range of 6–53 participants conducted across 12 nations that focussed on burns prevention, paediatric burns, appropriate acquisition and delivery of burns care, pain and psychosocial implications of burns trauma. Careful and rigorous application of qualitative methodologies promotes and enriches the development of burns knowledge. In particular, the key elements in qualitative methodological process and its publication are critical in disseminating credible and methodologically sound qualitative research. # 2015 Elsevier Ltd and ISBI. All rights reserved.
* Corresponding author at: Locked Bag 5052, Alexandria, NSW 2015, Australia. Tel.: +61 2 85727969. E-mail address: [email protected] (R.A. Kornhaber). http://dx.doi.org/10.1016/j.burns.2015.04.007 0305-4179/# 2015 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Contents 1. 2.
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5.
1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5. Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.6. Data reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. In which domains has qualitative research been used in burns research? . . . . . . . . 3.2. Why has qualitative research been used in burns research? . . . . . . . . . . . . . . . . . . . 3.3. How has qualitative research been used in burns research? . . . . . . . . . . . . . . . . . . . 3.4. How and where has qualitative research in burns been reported in the literature? . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Criteria for evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Limitations and strength of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Qualitative methods are progressively being implemented by researchers to explore aspects of healthcare that are untapped by quantitative methodologies [1]. Researchers have been utilising qualitative research methodologies since the 1960s [2]. However, there has been a longstanding and wide-ranging debate concerning the relative merits of qualitative research within the health care literature [3]. Despite qualitative research becoming more prominent in medicine and healthcare literature, it is a commonly held belief that qualitative research can only address limited research questions and therefore merely complement empirical approaches [4,5]. This may be due to researchers being well versed in quantitative research and unfamiliar with qualitative research and its central tenets. Therefore it is essential to convey that the unique position of the qualitative researcher is to ‘understand, explain, and demystify social reality through the eyes of different participants’ [6]. Quantitative research is objective in its approach and therefore aims to provide an overarching and often linear and normographic explanation rather than develop a deeper ideographic and complex understanding. Dingwall et al. [7] argue that qualitative research has a fundamental role in: addressing the gap between the filigndings of [randomised controlled trials]. . . and the practice of decision-making in individual cases with individual patients. The more individualised an intervention becomes, the greater the role that qualitative work is likely to play in its evaluation. Qualitative research has come under intense scrutiny and, at times, received harsh criticism from those in the medical profession [8]. Primarily utilised by those in nursing and the social sciences, qualitative research is a broad term for a diversity of methodological approaches. Qualitative methodologies allow the researcher to: challenge assumptions about
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health and illness; contribute to the development of theory for practice; offer a way to change how issues are conceptualised and enable one to see the world from another’s point of view that focuses on meaning, interpretation and understanding. Creswell [9] states that: ‘Qualitative research is an inquiry process of understanding based on distinct methodological traditions of inquiry that explore a social or human problem. The researcher builds a complex, holistic picture, analyses words, reports detailed views of informants, and conducts the study in a natural setting.’ The proliferation of qualitative research over the past decades has advanced health science, in particular nursing and the social sciences, contributing to the collective understanding of the experiences of health and illness. In recent years, qualitative research has gained considerable momentum with a noticeable shift towards the use of qualitative research methodologies that is evident in the number of qualitative peer reviewed publications globally. This trend is clearly noted over the last decade within the burns literature. A scoping search of burns research found that since 1998, there have been less than 100 published qualitative peer reviewed research papers exploring burn injury however over 40 of these have been published since 2009 alone. Among them, phenomenology, ethnography, grounded-theory, social constructionism and action research were methodologies utilised to explore and emphasise critical issues in burn care. Consequently, the utility of qualitative research as a rigorous, robust and systematic approach for health professionals investigating burns trauma warrants further exploration. Increasing complexity in burn care, combined with the rising trajectory of qualitative methodologies in burns research, supports the need for a current examination of the contribution to qualitative research in burns care and rehabilitation. Therefore, the aim of this study is to critically appraise the use of qualitative research in the field of burn management and rehabilitation.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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3
2.
Methods
focus across nursing, medicine and allied health related research literature.
2.1.
Review process
2.3.
Inclusion criteria
Integrative reviews are broader in the description and understanding of an area of research compared to a systematic review that addresses a specific clinical question [10,11]. An integrative review therefore has the potential to build knowledge presenting various perspectives on the phenomenon of interest [12]. Consequently the framework guiding this integrative review is based on Whittemore and Knafl’s [12] five stages: problem identification, literature search, data evaluation, data analysis and presentation (Fig. 1).
The search criteria for this integrative review incorporated peer reviewed reports of original qualitative research published in the English language within the last 5 years that described the management of burns including prevention, treatment, rehabilitation and psychosocial implications. As there has been a notable increase of qualitative methodological papers in the field of burns care, the 5-year range between 2009 to April 2014 was implemented to create a manageable sample for analysis. Abstract, conference proceedings, theses and editorials were excluded as were secondary sources and reviews.
2.2.
2.4.
Literature search
A systematic search was conducted of PubMed, CINAHL, EMBASE and SCOPUS database. Importantly, CINAHL was utilised as it is well known to use index terms that encapsulate qualitative research methodology [13]. Boolean connectors AND, OR and NOT were used to combine search terms as qualitative research, phenomenolog*, grounded theory, ethnograph*, action research and burn*. The aforementioned databases were chosen because they reflect a comprehensive
Data extraction
Two of the authors (R.K. and A.d.J.) independently appraised the data from each study and any disagreements were resolved by consensus discussion. This was conducted using the Joanna Briggs Qualitative Assessment and Review Instrument (QARI) Critical Appraisal Checklist for Interpretive and Critical Research. A total of 34 papers were reviewed of which 8 papers were excluded because they did not meet the inclusion criteria. On completion of the full review, 26 papers met the final criteria for inclusion (see Fig. 1).
2.5.
Data synthesis
The data analysis commenced with a narrative evaluation of the study’s characteristics. As there are various complexities that exist whilst evaluating primary sources of data when conducting an integrative review, analysis may become exceedingly complex. In addition, combining different research methodologies and data poses inherent risks that can lead to a lack of rigour, inaccuracies and bias [12]. Therefore our sample included primary sources of qualitative methodologies. Papers shown in Table 1 were converted from individual sources into a manner that assembles the data from multiple primary sources about particular variables or subgroups [12].
2.6.
Fig. 1 – Flow diagram of integrative review.
Data reduction
Whittemore and Knafl [12] recommend data reduction in accordance with ‘specific issues, variables or study characteristics. Of the 26 papers included, there was an average of 22 participants involved in each study with a range of 6–53 participants conducted across 12 different nations (see Table 1). Among the studies reported five key domains were identified: burns prevention, paediatric burns/parenting, appropriate acquisition and delivery of burns care, pain and psychosocial implications including concerning return to work, peer support, quality of life and coping and adapting. The methodologies utilised included narrative/thematic/content analysis, phenomenology, ethnography, grounded theory and social constructionism. Papers were cited on average seven times with a range from 0 to 22 with the more recent publications having no or few citations.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Table 1 – Integrative review sample by burn care context. Context Authors and origin
3.
Burns prevention
Paediatric burns/parenting
Deliver of care
Pain Yuxiang et al. [18], China Tengvall et al. [35], Sweden
Psychosocial
Durand et al. [15], UK
Ravindran et al. [40], India
Norouzi et al. [25], Iran
Van Niekerk et al. [16], South Africa Mashreky et al. [39], Bangladesh
Ravindran et al. [41], India
Abu-Qamar and Wilson [37], Jordan
Horridge et al. [20], UK
Abu-Qamar and Wilson [36], Jordan
Kornhaber et al. [22], Australia
McGarry et al. [14], Australia McGarry et al. [24], Australia
Dahl et al. [31], Sweden Badger and Royse [38], USA Sadeghi Bazargani et al. [17], Iran
Moi and Gjengedal [32], Norway Oster et al. [33], Sweden
Results
Findings were compiled to reflect the utility, rigour and credibility of the qualitative research framed by the following questions: (1) In which domains has qualitative research been used in burns research? (2) Why has qualitative research been used in burns research? (3) How has qualitative research been used in burns research? (4) How and where has qualitative research in burns been reported in the literature? Table 2 demonstrates the potential for qualitative to inform practice and improve outcomes in relation to burns prevention, delivery of burn care and rehabilitation of burn survivors.
3.1. In which domains has qualitative research been used in burns research? Qualitative research methodologies were utilised to explore experiences and phenomena of burn survivors and their families across the age continuum, e.g. [14,15] and in a cross section of burns management contexts including prevention, e.g. [16], pre-hospital management, e.g. [17], acute care, e.g. [18], rehabilitation, e.g. [19] and returning to work/school, e.g. [20,21]. Furthermore, qualitative methodologies were frequently implemented to explore psychosocial aspects of burns trauma, e.g. [22]. It is interesting but not surprising to note, that over half of studies identified were from a nursing origin as nursing aims to gather an in-depth insight and understanding of human behaviour, attitudes, values and beliefs, goals and culture perspectives as important aspects of nursing care. Furthermore, a qualitative methodology best addresses these aspects when exploring human nature. Papers from an allied health perspective have also featured in this review. Medical authors and co-authors are underrepresented and may reflect that academic medicine has not yet discovered the power of a qualitative or mixed methods approach.
Rossi et al. [27], Brazil
Badger and Royse [30], USA
Lau and van Niekerk [23], South Africa Mackey et al. [21], UK Ciofi-Silva et al. [19], Brazil Zhai et al. [29], China Rahzani et al. [34], Iran
3.2. Why has qualitative research been used in burns research? Each of the studies’ aims and objectives were reviewed for the terminology utilised. It was identified that verbs/verb phrases were used to describe the purpose including elaborate, illuminate, examine, describe, explore, discover and gain an indepth understanding. These verbs and phrases resonate with a qualitative approach in order to obtain a rich understanding of the core issues or processes burn survivors or their carers experienced so as to construct a thick description and a comprehensive account of the phenomenon. Quantitative research often relies on grouped data that averages scores to reduce variability and ‘simplify’ or ‘thin’ the picture. It often maps the spread of data with reference to means and standard deviations, using probability theory to develop specific hypothesis testing around differences between groups or differences over time. Qualitative research alternatively openly captures and explores the complexities and the depth of experiences and as such can be used to construct broader theory [4], for the exploration of ‘personal, social, cultural, spiritual, and other meanings and constructions’, and the detailed explorations of processes, tasks for which quantitative approaches can be less suited [23]. Consequently, qualitative methodologies were therefore primarily used to describe, illuminate and explore phenomena of interest to the field of burns. When the papers were examined for justifications to align method with the aims of the study authors offered rationales that related to the above notion of a detailed examination of complex phenomena. For example, in the area of burns prevention, McGarry et al. [24] used a phenomenological methodology (which provides greater insight into understanding human experiences with perception being pivotal to experiences) to describe the ‘lived experience’ of parents of children admitted to hospital for a burn and fundamentally sought to understand the essence of the individuals’ experiences. Norouzi et al. [25] used grounded theory to generate
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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Table 2 – Thematic analysis of burn care research domains. Context
Burns prevention
Paediatric burns/ parenting
Deliver of care
Pain
Psychosocial
Those seeking to introduce engineering-based scald prevention interventions in social housing need to emphasise potential environmental and financial impacts of water temperature reduction and the benefits of promoting safety for vulnerable populations. Safety education programmes are reported to be an effective intervention in improving knowledge and practices of rural people in lower income countries with regard to prevention of burns injuries in paediatric populations. Although implementation of these programmes in low income settings are problematic.
Childhood burns were reported to be painful and traumatic for both the child and parents. Confidence along with role adaptation, acceptance was pivotal in the return to school process. Culture of blame was encountered among parents. Parents endured the process of blame. Parents will benefit from ongoing assessment and psychological interventions that will provide emotional support. Parents in turn perceived minimal support from health professionals and family members. Stressors, behavioural and emotional responses and coping factors were commonly reported. Further support for parents and their burned children would complement and support the existing surgical and medical treatment plan, providing direction for comprehensive service delivery and improved psychosocial outcomes in children.
Unintegrated care emerges as a fundamental issue for burn survivors. Burn survivors require adequate reinforced education about the plan for their burn care, the physiological changes, more involvement and social support to cope with the traumatic event. Culturally specific health education programmes should be made to raise patients’ awareness towards avoiding possible burn risks. Inappropriate perceptions regarding initial management of burns existed. Respect, communication and provision of competent care were identified as fundamental elements in delivering competent burn care.
Pain was a fundamental issue in the treatment of burn injury and often reported as undertreated. Adequate pain management facilitated boosting self-confidence and inner strength. Freedom from pain was noted to be an unrealistic notion as burn survivors endured the experience of pain mostly alone. A multidisciplinary approach in the treatment of pain is fundamental in the rehabilitation of burn survivors.
Burn survivors struggled with their injury and how they perceived life after rehabilitation with implications for quality of life, adapting and coping. Findings revealed positive insight concerning the value of social and peer support in providing a sense of belonging, hope, resilience and facilitated with acceptance, coping strategies and greater selfawareness and personal growth. Goal setting enabled return to work/ school and an improved quality of life. However, pain, limited knowledge, lack of individualised rehabilitative care and psychosocial support inhibited return to work and activities of daily living. Understanding these concepts through the burn survivors’ perspective has the ability to facilitate a better understanding of how to best navigate psychological adjustment, return to work/school and social reintegration. These collective results show the importance of the sociocultural dimension in the concept of quality of life for persons undergoing burn rehabilitation. The use of structured educational programmes and organising peer support has significance for support from family, friends and health professionals.
Findings
theories regarding social phenomena and develop higher level understanding that is ‘grounded’ in, or derived from, a systematic analysis of data [26] concerning the rehabilitation care process in patients who were burn-injured as a result of self-immolation. Rossi et al. [27] employed an ethnographic design exploring social interactions, behaviours, and perceptions that occur to illuminate the cultural meaning and dimensions of quality of life from the perspective of Brazilian burn patients. Lau and van Niekerk’s [23] research was informed by social constructionism, which is primarily concerned with illuminating the process by which individuals come to describe or explain the world in
which they reside and attempt to express common forms of understanding that have been socially negotiated [28]. Zhai et al. [29] utilised a qualitative approach to explore whether the phenomenon of post-traumatic growth would be found in a Chinese sample to substantiate that the phenomenon was cross cultural and that the dimensions tapped by a previously developed questionnaire score, the Posttraumatic Growth Inventory, adequately tapped the Chinese mainland experience. In this example the qualitative approach was used to explore whether the quantitative method developed in another cultural context had construct validity in the new context.
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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3.3. How has qualitative research been used in burns research? Qualitative research can access information via a number of routes: interviews of individuals, members of families/ systems or focus groups, where the participants have a direct voice; observations of participants (often as field notes) where action and interactions are described by the researcher; detailed examination and analysis of artefacts: art, music, texts, such as diaries. In the papers selected the overwhelming majority of papers used semi-structured interviews of individuals [16,18,20– 24,30–35] and two studies used unstructured interviews [36,37]. In one study the nature of the interview as structured or unstructured was not clarified [15]. Other studies used focus groups as the interview approach [17,38,39]. One study used a mix of interviews and a reflective diary [29]; three others used a mix of interviews and observation [27,40,41]. One used a combination of all three qualitative approaches [25] and one study used a modest combination of qualitative and quantitative methods [19]. The above spread of approaches, clustered around the semi-structured individual interview might suggest that the qualitative methodologies are still new in burns research, emphasising the qualitative experience of small research teams and groups. The potential for mixed methods approaches, which require collaborations between quantitative and qualitative approaches, and often allow a multidisciplinary or inter-disciplinary approach is as yet untapped.
3.4. How and where has qualitative research in burns been reported in the literature? The publications selected encompassed a broad area of burn care ranging from prevention to rehabilitation and the long term psychosocial implications from a multiplicity of settings and cultural backgrounds. Qualitative research publications in the area of burn management and rehabilitation were published across several disciples including nursing [18,19,25,27,29,31–36,40,41], social work [23,30,38], occupational therapy [14,24], public health [15,16], medicine/surgery [21], psychology [20], epidemiology [16,17,39] and rehabilitation [19,22] demonstrating a wide and diverse scope. Of significance was the large percentage of papers published in peer reviewed journals with an impact factor including the Journal of Clinical Nursing [25,32], Burns: Journal of the International Society for Burn Injuries [14,15,17,18,20–22,34,40], International Journal of Nursing Studies [41], Journal of Burn Care and Research [31,35,38] and Public Health [16,39]. Papers published in peer reviewed journals denote research of high quality, with methodological rigour that is judged and valued by peers. Therefore rigorous, robust and systematic qualitative publications in peer reviewed journals supports and facilitates the use of qualitative methodologies in burn care and rehabilitation. Based on the breadth and depth of peer reviewed publications cited in this integrative review, it is evident that qualitative research in the period has explored critical issues in burn care and contributed to the expanding body of burns knowledge and is now placed alongside the quantitative burns literature. It is likely that it will continue to be a visible
presence in mainstream burns research. Perhaps the fundamental value and utility of qualitative research methodologies is beginning to be realised.
4.
Discussion
The purpose of this critical assessment was to critically appraise the use of qualitative research in the field of burn management and rehabilitation. The following discussion will encompass the criteria for evaluation and the limitations and strength of evidence of this integrative review.
4.1.
Criteria for evaluation
Statements locating the research within a sociocultural framework [15–17,19–21,29,30,36,37,39–41] were common in the papers identified and speaks to a strength of qualitative approaches. Fewer papers clearly identified a theoretical perspective [18,23,27,29,32,34,38]. Investigators are an integral part of the research process [3]. Hence, Bailey et al. [42] states that the broader application of qualitative research in healthcare has been accompanied by a resounding concern to establish what actually represents and comprises methodologically rigorous qualitative research. As a result, qualitative research is at risk of criticism with claims that it is subjective and anecdotal, prone to researcher bias (conscious or unconscious) [4]. Furthermore, tension remains around qualitative research methodologies from social sciences and building evidence from practice [43]. Practices as triangulation are reported to address the issue of internal validity by the use of more than one method of data collection in order to answer the research question, check and establish validity in their studies by analysing a research question from multiple perspectives. Where appropriate, member checking whereby key themes and findings are returned to the participants to attain congruence between both the researcher and participants’ perceptions are key aspect in the establishment of credibility [44] and enables the participant the opportunity to validate their transcripts and the interpretations of the findings [45]. Lincoln and Guba [44] postulate that this is a critical technique for establishing credibility however, member checking remains highly controversial among qualitative researchers reflecting diversity in criteria to rigour depending on the question being posed [46,47]. Multiple coding which is likened to inter-rater reliability within quantitative research, where possible, can further reduce researcher bias and strengthen the study’s credibility and rigour and was used in several of the studies selected. Multiple coding involves two or more researchers analysing the same data transcripts and comparing and contrasting their findings. However, when revisiting data, interpretations of their data may shift over time [48]. Furthermore, given the complexity of qualitative data and the diverse background and scope of researchers, there are variations in the approach taken to code frameworks, in particular the language utilised [49]. Depending on the methodological framework, concepts such as bracketing utilised in descriptive phenomenology inquiry require the researcher to consider preconceptions, biases and assumptions related to the phenomenon prior to
Please cite this article in press as: Kornhaber RA, et al. Rigorous, robust and systematic: Qualitative research and its contribution to burn care. An integrative review. Burns (2015), http://dx.doi.org/10.1016/j.burns.2015.04.007
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and throughout the study [50] in order to reduce the likelihood of misinterpretation and contamination of the raw data. However, uncontaminated data makes it difficult to test findings using qualitative methods. Within some schools there is room/scope for qualitative researchers to develop this aspect of practice. Lastly, it is also imperative to account for negative cases which oppose the developing explanations. Examples such as these methods described are necessary to implement where appropriate, so as to attain a robust, rigorous and systematic approach to qualitative research. However, it is interesting to note that Barbour [51] suggests that the use of these strategies does not in itself, confer rigour as a broad understanding of qualitative research design and data analysis is necessary and only then can these strategies strengthen the rigour of qualitative research.
4.2.
7
address the phenomena of burn management in its complexities. Although some still regard qualitative methods as fundamentally inferior to the previously mainstream quantitative approaches, it is to be hoped that health professionals and researchers, including medical professionals become familiar with the richness and scope afforded by qualitative and mixed methods research in burns. This is especially pertinent now, where there is currently a changing health climate which demands an increasingly greater evidence-base alongside patient and carer participation, and the rigorous assessment and evaluation of outcomes and services via methods that respect the individual and their cultural context and preserve aspects of process and lived experience.
Conflict of interest
Limitations and strength of evidence The authors declare that they have no conflict of interests.
Despite the review identifying that a majority of the selected studies did report the use of appropriate methods to demonstrate rigour, credibility and trustworthiness, a lack of philosophical detail underpinning the studies was evident with only a few papers addressing the philosophical, conceptual or theoretical background of the methodology. For example, confusion seems to remain surrounding the concept of sample size which is a redundant concept within qualitative research. It is the notion of data saturation that is a key element in qualitative methodologies: the point at which data collection ceases as no new information is forthcoming [52]. The resultant data are quality driven not sample size dependent. Without data saturation qualitative research lacks rigour and may be deemed invalid. In some cases, there may only be a few people eligible to be involved in the research because of the uniqueness of the investigation.
5.
Conclusion
Qualitative research has the ability to capture the perspectives and experiences of those involved in the phenomenon of burn injury and rehabilitation and to contribute to the emerging body of knowledge and research on the process of rehabilitation. This has the capacity to improve patient outcomes, care practices and to influence health policy in the local, national and international arenas. Given the psychosocial aspects of burn management, qualitative research methodologies are a prime approach to explore burn survivors’ unique experiences in a rigorous, robust and systematic manner. Both qualitative and quantitative research continues to coexist within burns literature as both paradigms have been acknowledged to inform clinical practice and resulted in improved outcomes. However, controversy has remained till recently around whether qualitative research can address clinical and biopsychosocial research questions. In many cases, quantitative research is the most appropriate method to answer questions posed in healthcare. However, qualitative research is deemed fit to tackle innovative questions arising out of contemporary health care. Intrinsically, qualitative methodologies are well entrenched in nursing research and have more recently shown themselves to be well-accepted methodological approaches to
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