I joined the Healthwatch Essex team as a Research Officer in December 2021. Prior to this, I worked as a Registered Nurse for ten years. For the last two years, I had been working as a Cardiovascular Research Nurse in a large acute NHS Trust and completed my MSc in Public Health. A key motivation for joining the HWE team, was the chance to be involved in conducting and delivering qualitative research, built upon people’s lived experiences. This would also mark the beginning of my journey from working in previously quantitative-heavy research settings to a qualitative one. In this blog, I will reflect on this transition and on the transferable lessons, applicable to both quantitative and qualitative research, that I have learnt along the way.
Quantitative design in clinical research is often correlational, quasi-experimental or experimental in nature (Vázquez Navarrete, 2009). As a Research Nurse, I would often recruit and follow-up with those enrolled onto randomised controlled trials (RCT) or observational cohort studies. In experimental RCTs, participants are randomly assigned to intervention or control arms, with distinct ‘before and after’ points of measurement (Carneiro and Howard, 2011). Intervention may be a medicinal product or novel procedure. The control arm may be exposed to a placebo or the usual standard of care. Participants are measured before the administration of a specific treatment (these early measurements are often referred to as ‘baseline’ measurements) and these will be repeated and recorded again after the treatment for a determined period of follow-up (Carneiro and Howard, 2011). These defined measurement points apply to both the intervention and control arms. Observational cohort studies are longitudinal and follow a sample of participants who share a particular characteristic (Vázquez Navarrete, 2009). There is no intervention administered during an observational cohort study. Cohort studies I had previously worked on, often followed the long-term health outcomes of those who had been hospitalised with a particular disease (most recently, this included a cohort hospitalised with covid-19). Regular clinical assessments over the course of a year tracked changes in symptoms and physiological functioning of bodily systems such as the neurological system, respiratory system etc.
Both quantitative and qualitative research can inform and shape health and social care services, and help us understand health, wellbeing, and disease. Rather than viewing qualitative research as purely complementary to quantitative, both should be viewed with the potential to address informational gaps in the other’s findings and answer original research questions in their own right. Quantitative study designs can measure the effectiveness of a proposed treatment or clinical intervention, establish causality and measure service usage etc. However, qualitative study designs can inform us of why a service is/isn’t accessed, revealing economic, social and other upstream contextual factors affecting health and understanding of complex health behaviours. It was the questions of why in the field of public health and health services research that fascinated me the most, and that appeared to yield the valuable insight for those of us passionate about health promotion and illness prevention.
When working on an RCT in an ‘unblinded’ capacity (whereby the researcher is aware of whether the participant was allocated to a treatment or control arm of an intervention), there is potential to observe what is referred to as the ‘placebo effect’. This is where a participant has been allocated to the control arm and receives no active substance or procedure, but reports or exhibits a response which would otherwise be associated with active treatment (e.g. a measurable reduction in blood pressure on a study of hypertension). Quantitative tools of measurement may capture the response but are limited in terms of explaining why this had happened. In an RCT where the participant themselves remained blinded to their allocation, it was important not to enter into a line of questioning that would reveal their randomised allocation. Preservation of the trial arms and replicability of study methods are important in randomised controlled trials. This scenario often had me reflecting on the worth qualitative methods could yield in exploring this placebo effect phenomenon, and the value of understanding a participant’s lifeworld. Contextual factors are not merely confounders to be randomly distributed among trial arms. Did engaging with research make participants feel that they were more closely monitored and thus affect measurements? If psychologically, you believe you are receiving active novel treatment, will this manifest physiologically? Did trial participation lead the individual to initiate a number of lifestyle changes that they had not previously?
Thinking back to my encounters with this phenomenon allowed me to compare and reflect on my role as I made the change from quantitative to qualitative research. The researcher in quantitative research is considered an invisible instrument, solely concerned with data collection and entry. Studies should be replicable and generate similar results regardless of who the researcher is. In qualitative studies, the researcher is made more visible: encouraged to consider their own subjectivity, potential biases and previous experiences (Denzin and Lincoln, 2012). There is also a lot of ‘invisible’ work that a researcher will undertake that is not captured in research protocols: the building of rapport and maintenance of trust between researcher and participant, for example. Work in relationship building and ensuring participant engagement often contributes to study retention. This ‘invisible’ work, alongside reflections on subjectivity and study experiences, can be captured in a reflective journal during qualitative research. Thus, it can feel that the researcher is less invisible during qualitative work.
My initial thoughts when beginning to handle and collect qualitative data included: As an interviewer, can I delve further or expand on interview questions? Or should I adhere verbatim to the interview guide? Does my previous background affect my worth as an equal during data triangulation? This internal questioning was gradually overcome with the help of a supportive Research Manager and the exploration of the emic (insider) and etic (outsider) researcher in qualitative studies. I would remind myself that an effective qualitative researcher knows when to probe and expand on interview questions, and appreciates the value of depth (Brinkmann and Kvale, 2015). I also revisited my motivations for studying my MSc, joining Healthwatch Essex and my desire to move away from quantitative study designs.
Many skills are also transferable from the quantitative to qualitative field: skills such as rapport building, effective communication and understanding a proposal’s instruments of measurement and managing participant expectations. I have spoken about managing participant expectation elsewhere (Orriss-Dib, 2021) and believe strongly in engagement and rapport building as factors in study recruitment and retention. It is important to acknowledge that people participate in research voluntarily, and we must respect that they have given us a notable portion of their time. When exploring and capturing the lived experience, it is also fundamental that the researcher appreciates the role of the participant in revealing their lifeworld.
Reflecting on this journey, I reminisced about patients I had encountered early in my nursing career and recalled the awe I felt at how they demonstrated frequently their adaptability in challenging situations. This served as a lesson that was worth revisiting again: If they can be adaptable in times of change, I can too. As with most situations requiring adaptability, it is time to draw upon existing transferable skills, while keenly learning new ones as well.
Brinkmann, S. and Kvale, S. (2015) Interviews: Learning the Craft of Qualitative Research Interviewing. 3rd edn. SAGE Publications.
Carneiro, I. and Howard, N. (2011) Introduction to epidemiology (Understanding Public Health). 2nd edn. Glasgow: Open University Press.
Denzin, N. and Lincoln, Y. (eds) (2012) The Landscape of Qualitative Research. 4th edn. California: SAGE Publications Inc.
Orriss-Dib, L. (2021) ‘The research nurse’s role in managing patient expectation in clinical trials’, Nursing Times, 118(2). Available at: https://www.nursingtimes.net/roles/clinical-research-nurses/the-research-nurses-role-in-managing-patient-expectation-in-clinical-trials-10-01-2022/ (Accessed: 19 April 2022).
Vázquez Navarrete, M. (2009) ‘Qualitative and quantitative methods in health research’, International Journal of Integrated Care, 9(5). doi: 10.5334/IJIC.377.