The Value and Potential of Qualitative Research Methods in Neurosurgery.

OBJECTIVE: To explore the value and potential of qualitative research to neurosurgery and provide insight and understanding to this underused methodology.
METHODS: The definition of qualitative research is critically discussed and the heterogeneity within this field of inquiry explored. The value of qualitative research to the field of neurosurgery is articulated through its contribution to understanding complex clinical problems. DISCUSSION: To resolve some of the misunderstanding of qualitative research, this paper discusses research design choices. We explore approaches that use qualitative techniques but are not, necessarily, situated within a qualitative paradigm in addition to how qualitative research philosophy aids researchers to conduct interpretive inquiry that can reveal more than simply what was said by participants. Common research designs associated with qualitative inquiry are introduced, and how complex analysis may contribute more in-depth insights is explained. Approaches to quality are discussed briefly to support improvements in qualitative methods and qualitative manuscripts. Finally, we consider the future of qualitative research in neurosurgery, and suggest how to move forward in the qualitative neurosurgical evidence base.
CONCLUSIONS: There is enormous potential for qualitative research to contribute to the advancement of person-centered care within neurosurgery. There are signs that more qualitative research is being conducted and that neurosurgical journals are increasingly open to this methodology. While studies that do not engage fully within the qualitative paradigm can make important contributions to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.

Introduction

This paper explores the value and potential of qualitative research to the field of neurosurgery. We argue that qualitative research is underused and misunderstood, yet including qualitative research in neurosurgical study designs can lead to improved provision of person-centered care. While this paper cannot be a comprehensive review of the many discourses and debates within qualitative research, it does offer insight, understanding, and practical advice.

Background: What Is Qualitative Research, What It Is Not, and Why Conduct Qualitative Research in Neurosurgery?

What Is Qualitative Research?

There is no one way to conduct qualitative research. Instead, qualitative research is an umbrella term for a heterogenous field of inquiry. While this heterogeneity causes some challenges (see Aspers and Corte for a critical discussion of what is qualitative research), broad principles characterize this approach.

Qualitative researchers attempt to understand events and experiences through detailed descriptive and interpretive analysis of people’s experiences, views, perspectives, and perceptions of their social reality. Most commonly (but not exclusively), qualitative studies use in-depth, non-numerical data collection methods to explore participants’ experiences. These methods can reveal important insights not possible from research driven by quantitative methods alone. There are a number of different definitions that illustrate qualitative research’s core commitments:

…any type of research that produces findings not arrived at by statistical procedures or other means of quantification

…qualitative research involves an interpretive, naturalistic approach to the world. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or to interpret, phenomena in terms of the meanings people bring to them

…an iterative process in which improved understanding to the scientific community is achieved by making new significant distinctions resulting from getting closer to the phenomenon studied

From these definitions, we can extrapolate that qualitative research commonly attempts to make sense of naturally occurring events using approaches that are non-numerical, interpretive, and iterative. However, there are circumstances in which qualitative research is used to understand events that have not occurred naturally, such as their use in experimental designs. Analysis may include numerical data, favor description over interpretation, and proceed in a linear rather than iterative fashion. These diverse approaches, and their application, make the field of qualitative research rich and complex and why a comprehensive review of all qualitative research is beyond the scope of this manuscript.

What Is Not Qualitative Research?

At first glance qualitative studies may appear unscientific or anecdotal. Studies with small sample sizes may also bear some resemblance to case reports and case series. However, as a research strategy, rigorous qualitative research remains a systematic form of empirical inquiry based on explicit sampling and in-depth analytical approaches. In contrast, case reports and case series are “publication types” and should never be considered qualitative research.

Why Conduct Qualitative Research in Neurosurgery?

Simply put, numbers are never enough to completely understand or improve patient care. Not every question can, or should, be answered numerically. Valid measures may be able to identify the presence or absence of an outcome yet do not tell us why these outcomes exist. Furthermore, where there is little, or no, previous understanding of a subject it is simply not possible to have large group interventions or valid questionnaires. It is here, within the “unknown,” that qualitative research finds its voice and is a powerful tool to understand clinical problems.

A search for qualitative research in neurosurgical journals specifically is evidence of the underuse of this approach. Restricting the neurosurgical evidence base in this way may have a detrimental effect on advancing patient care because different neurosurgical research questions need different research designs. Qualitative studies make an important contribution to evidence-based practice and neurosurgery is no exception. In an editorial in the Journal of Neurosurgery, Khu and Midha call for more qualitative research to understand the patient perspective:

The use of qualitative research in total avulsion brachial plexus injuries (BPIs) fills a void not addressed or explored by quantitative research. Clinicians are mostly concerned about treatment options and outcomes, but little has been written about the patient perspective of the disease. […], it is imperative that we understand the condition from the patient’s standpoint to help them make informed decisions about their treatment.

Examples of recent qualitative studies include exploring patient perceptions of neurosurgery, medical errors, communication and decision making. In addition to neurosurgeons’ perspectives on long-term follow-up and their ability to conduct and disseminate clinical research (see these and others in Table 1). These studies need an open and curious approach that starts by asking “how and why” not “if and how many.”12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24

Table 1

Neurosurgical Topics and Research Aims Examined in Studies Using Qualitative Methods

Topic	Research aim
Neurosurgical patient experiences	➢ To explore in-depth patients’ experiences and learn their perspectives at various stages of the Gamma Knife stereotactic radiosurgery process, from the initial referral to treatment to follow-up.12
Neurosurgical patient attitudes and perceptions	➢ To explore attitudes toward neurosurgery in a resource-poor setting.13 ➢ To examine patients’ perceptions and attitudes regarding medical error in patients facing brain tumour surgery.14 ➢ To explore patients’ perceptions and feelings regarding carpal tunnel syndrome and ulnar nerve entrapment outpatient decompression surgery.15 ➢ To explore patients’ perceptions about awake and outpatient craniotomy.16
Neurosurgical patient decision-making	➢ To understand the perspectives and experiences in medical decision-making for patients selecting management for unruptured intracranial aneurysms.17
Neurosurgical patient education	➢ To further explore neurosurgery patients’ and caregivers’ perceptions of the extent to which communication and patient education preoperatively, during hospitalization, and at discharge from hospital met their needs and expectations.18
Neurosurgical patient information needs	➢ To explore the information needs of neurosurgical patients with nonmalignant but potentially life-threatening conditions.19
Neurosurgical careers	➢ To explore how social media could be used to influence an individual’s motivation to pursue a neurosurgical career.20
Neurosurgical research capacity	➢ To understand neurosurgeons’ experiences of, aspirations for and ability to, conduct and disseminate clinical research in LMICs.21
Neurosurgical decision making	➢ To explore approaches to intraoperative decision-making among pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children.22
Neurotrauma long-term follow-up	➢ To understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs.23

LMICs, low- and middle-income countries; TBI, traumatic brain injury.

To explore in-depth patients’ experiences and learn their perspectives at various stages of the Gamma Knife stereotactic radiosurgery process, from the initial referral to treatment to follow-up.

To explore attitudes toward neurosurgery in a resource-poor setting.

To examine patients’ perceptions and attitudes regarding medical error in patients facing brain tumour surgery.

To explore patients’ perceptions and feelings regarding carpal tunnel syndrome and ulnar nerve entrapment outpatient decompression surgery.

To explore patients’ perceptions about awake and outpatient craniotomy.

To understand the perspectives and experiences in medical decision-making for patients selecting management for unruptured intracranial aneurysms.

To further explore neurosurgery patients’ and caregivers’ perceptions of the extent to which communication and patient education preoperatively, during hospitalization, and at discharge from hospital met their needs and expectations.

To explore the information needs of neurosurgical patients with nonmalignant but potentially life-threatening conditions.

To explore how social media could be used to influence an individual’s motivation to pursue a neurosurgical career.

To understand neurosurgeons’ experiences of, aspirations for and ability to, conduct and disseminate clinical research in LMICs.

To explore approaches to intraoperative decision-making among pediatric neurosurgeons when they encounter unexpected events, uncertainties, or complications while operating on children.

To understand the contextual challenges associated with long-term follow-up of patients following TBI in LMICs.

Until more recently the contribution of qualitative research to evidence-based practice, had been viewed as less valuable than evidence generated through statistical measurement., Despite this, a bibliometric and altmetric comparison of the impact of qualitative and quantitative research concluded that both had similar academic impact. Furthermore, a qualitative study on the effects of deep brain stimulation on the lived experience of obsessive-compulsive disorder patients has been viewed more than 8000 times, with 80 downloads and 54 citations (metrics obtained from Scopus).

There is therefore evidence that qualitative research is valued and is increasingly published., However, there is some concern that qualitative research is not well understood in medical journals and some well-conducted research papers are being rejected. This paper aims to reduce this knowledge gap by discussing design choice and quality in qualitative studies.

Discussion: How to Design Qualitative Neurosurgical Research

Having established that qualitative research is valuable in neurosurgery the discussion now attends to the question of how to design qualitative neurosurgical research. Qualitative research extends beyond the mere collection of qualitative data and associated techniques (methods) to the application of these techniques within a qualitative paradigm (methodology). The distinction between qualitative methods and qualitative methodology is important and has been referred to as small q versus big Q., While this distinction may be too binary to reflect the heterogeneity within the field of qualitative inquiry, it is useful to think about studies that are designed to simply use qualitative techniques but are not overly concerned with qualitative thinking, and those which engage fully with qualitative theory and use this to enhance their research design. For example, researchers may want to know more about patient acceptability of a neurosurgical intervention while participating in a randomized control trial. Researchers in this study may value the quantification of relevant themes or concepts to answer their research question. In contrast, researchers may want to understand the lived experience of surviving severe head injury. This research is more likely to value in-depth interpretive themes to answer the research question, relying less on quantification and more on meaning, and as such be designed within a qualitative paradigm. These researchers will need to have discussions about the nature of reality and knowledge (i.e., ontology and epistemology) during the design of their research as these decisions will shape the research design. These decisions should be explicit in protocol development and the associated manuscript for publication.

Selecting a Research Design

As a heterogenous field of inquiry, there are a large number of qualitative research designs (see Figure 1; however, we recognize this figure is incomplete, and that many authors would reject a restrictive typology). On the left are approaches not necessarily anchored by philosophy or theory (although it is important to note that some say research without theory is impossible because no study can be designed without some influence or guiding interest)., In contrast on the right are those firmly anchored in their own epistemological and ontological world views. These designs are often, but not always, associated with more complex and sensitive analysis and will by that nature take longer to complete. However, these appear to be less common in the medical literature.

Figure 1

Continuum of qualitative research.

Designs on the left are thematic approaches most closely aligned to quantitative principles, describing the patterns in the data through counting the presence of certain features of interest. Therefore, these studies often retain their foothold in (post)positivist assumptions and rely heavily on rigid procedures, coding frames, and inter-rater reliability of coding decisions. Examples include content and framework analysis; however, there are also ways of conducting these studies that adopt a more interpretive stance. Such studies tend to be more common in the medical literature.

Another popular thematic approach is the method described by Braun and Clarke, which has now been cited more than 90,000 times. However, this proliferation has led to some dubious qualitative studies that present little of the analytical rigor required of this approach. To counteract this misrepresentation, Braun and Clarke more recently labeled their approach as “reflexive thematic analysis” to emphasize the subjectivity and reflexivity that is central to its interpretive stance. Reflexivity in qualitative research is defined as: The process of critical self-reflection about oneself as researcher (own biases, preferences, preconceptions), and the research relationship (relationship to the respondent, and how the relationship affects participant’s answers to questions). Therefore, reflexive thematic analysis is situated within the center of the continuum to illustrate its roots in a qualitative paradigm but its freedom from specific ontological and epistemological anchors.

To help differentiate these research approaches, Table 2 provides some hypothetical neurosurgical research questions and the nature of the findings achieved using these different designs., On the right-hand side of Figure 1 are highly interpretive designs that do have specific ontological and epistemological anchors. The “big five” are phenomenology, narrative, ethnography, grounded theory, and case study (not to be confused with case reports or case series; case study methodology involves complex systematic analysis, multiple forms of data and are an explicit qualitative design). There also others including discourse analysis, conversation analysis and action research. While there are some commonalities, these are all very different and have specific methods to support complex in-depth, and interpretive, analysis (see Table 3 and Creswell and Poth for a useful comparative text).,42, 43, 44, 45, 46, 47, 48

Table 2

Comparison of Qualitative Research Approaches

Qualitative Research Design	Main Focus of Inquiry	Common Subdivisions	Example Question	Nature of the Findings
Content analysis	Determine the presence of items of interest within the data set	Conceptual/relationalConventional/directed/summative	What are the specific discharge concerns of children with hydrocephalus?	Descriptive or interpretive themes with an emphasis on quantification.
Framework analysis	How does an a priori theory explain the study data?	Five-stage analysis protocol.39Seven-stage analysis protocol.40	Patient perspectives on risk-taking behavior leading to head injury.	Understanding of what can, and cannot, be explained by current theory.
Reflexive thematic analysis37	In-depth, reflexive interpretation of the data.	N/A	Women’s experiences of becoming a neurosurgeon.	In-depth interpretive themes.

N/A, not available.

Table 3

Comparison of Qualitative Research Approaches (Cont.)

Qualitative Research Design	Main Focus of Inquiry	Common Subdivisions	Example Question	Nature of the Findings
Phenomenology	The essence of experience	Descriptive; interpretive; interpretive phenomenological analysis (IPA)42	What is the lived experience of neurosurgeons during the COVID-19 pandemic?	In-depth understanding of the individual experience.
Narrative	Exploring the individual life story	The ‘what’ of a story; The ‘how’ of a storyBiographical43; life story; oral history, Labovian44	How do patients live with, and make sense of, neurological disability post-neurosurgery?	Individual stories, life courses, sense making, identity, relationships.
Ethnography	Cultural interpretation	Realist, critical, rapid, case study	What are the working practices of staff in a neurosurgical department?	Understanding of practice, behavior, attitudes and how these contribute to the resultant culture.
Grounded theory	Developing theory	Classical45; Straussian6; constructivist46	How do patients adjust to acute ward settings following discharge from neurocritical care?	Generation or discovery of theory/explanation.
Case study	Examination of a bounded system	Intrinsic; instrumental; collective47Descriptive; explanatory; exploratory48	How do neurocritical care departments implement and evaluate new neurosurgical guidelines?	In-depth understanding of the key facets within a system and the barriers and facilitators driving change.

COVID-19, coronavirus disease 2019.

Quality in Qualitative Research

Given the range of qualitative approaches strategies to increase quality in qualitative studies should be commensurate with the chosen design and its associated philosophy. For example, a study using phenomenological inquiry should not be forced to use procedures more appropriate for a content analysis (or vice versa). Furthermore, the field of qualitative inquiry is constantly evolving and views evolve with it. For example, the “reliability” of analysis, where participants and researchers reach the same conclusions, may have been previously prioritized through checking the accuracy of coding decisions and interpretations, member checking, respondent validation and peer review. In contrast, emphasis has more recently been given to using these methods to advance interpretation rather than check analysis to reach a more meaningful conclusion.

Despite this ongoing dialogue, there are common strategies that can improve the quality of qualitative research (Table 4). These techniques should be discussed during protocol development. Some studies will use very few of these, others will use many; unfortunately, some will use none. However, all qualitative studies should employ some strategies to improve quality. The choice of which and why should be informed by the research question, methodology and philosophical position of the study. In addition, the 32-item Consolidated Criteria for Reporting Qualitative research (COREQ) also can help researchers to develop a robust protocol. Understanding what should be reported in a qualitative manuscript, before the study is conducted, can improve its quality and subsequent impact.

Table 4

Strategies to Increase Quality in Qualitative Research

Domain	Strategy	Methods
Credibility	Prolonged engagement	Long interviews and/or observationsLongitudinal designsMultiple data collection points
	Triangulation of data and methods	Multiple sources of data, multiple researchers, multiple methods
	Member checking	Returning data to participants to check accuracy
	Respondent validation	Checking interpretation of data with participants and building responses into the analytical process
	Expertise	Consultation/supervision from a qualitative expertEvidence of qualitative training
	Peer debriefing	Sharing of analysis with peers to sense check meaningful interpretation
Dependability and confirmability	Audit trail	Clarity of methods and procedural rigor reported in a study.Transparency of process involved to analyze data from codes to findings
	Authenticity	Present raw data in the form of direct quotesEnsure participants are fairly represented, i.e., do not overly rely on quotes from one personFindings are well grounded and supportable
Transferability	Thick description	Contextual/demographic information for participantsProvision of rich detailed quotes
Reflexivity	Diary	Maintain a reflexive diary and use in the analytical process

The Future of Qualitative Research in Neurosurgery

Table 5 suggests a number of contemporary neurosurgical research questions where a qualitative approach would make a valuable contribution to the evidence base. However, there are many others and neurosurgeons are encouraged to explore how qualitative studies may advance their own professional practice and patient care.

Table 5

Contemporary Neurosurgical Qualitative Research

Subspeciality	Future Research Areas
General neurosurgery	➢ Neurosurgical patients’ perioperative concerns ➢ The meaning of illness to neurosurgical patients and families ➢ Factors affecting neurosurgical trainee satisfaction ➢ Neurosurgical program evaluation
Functional	➢ Patients’ perceptions of deep brain stimulation surgery ➢ Patients’ perceptions of seizure surgery ➢ The impact of epilepsy on patients’ work and social life
Paediatric	➢ Parents’ expectations after surgery for tethered cord ➢ Impact of brain tumor surgery on an adolescent patient
Vascular	➢ Why patients select coiling or clipping for ruptured aneurysms ➢ Patients’ perceptions on having an unruptured intracranial aneurysm
Spine	➢ Patients’ perceptions of kyphosis surgery ➢ Perspectives in clinical decision making in patients with cervical spondylosis manifesting only with pain
Oncology	➢ Patient and caregiver perceptions about palliative care ➢ Physicians’ attitudes toward end-of-life care
Trauma	➢ Caregivers’ perceptions of outcome following neurosurgery
Peripheral nerve	➢ Patients’ perceptions of brachial plexus repair surgery
COVID-19	➢ The impact of a global pandemic on neurosurgeons and neurosurgical patients ➢ Lessons learned during a global pandemic for the provision of neurosurgical care.

COVID-19, coronavirus disease 2019.

While qualitative research is finding its place within the neurosurgical evidence-base, this brings with it an opportunity to harmonize the contrasting epistemological and ontological positions that has led to their historical separation and years of debate known as the “paradigm wars.” There is a rich opportunity to mute the differences between these and design more mixed methods studies where qualitative methods are used to enhance understanding reached through quantitative analysis. That said, reducing qualitative research to a procedural variation that prioritizes method over methodology has been criticized. For example, studies that use a few direct quotes to support a P value limit the contribution of qualitative research. It is argued that by improving understanding of high-quality qualitative research, we can open up the possibility of genuine mixed methodology that draws the best that both types of research can offer.

We would also encourage more studies that engage fully in the philosophical and theoretical complexities of qualitative inquiry. Such studies lend themselves to more complex and nuanced interpretations of the lived experience. However, to achieve this, methodological knowledge must be grown to ensure neurosurgical qualitative research continues to develop in a way that is commensurate with this field of inquiry. Commitment should also be made to the time that such complex investigations necessitate.

Beyond neurosurgery, qualitative inquiry continues to advance. While traditionally, qualitative researchers have prioritized in-person data collection, the pandemic has seen researchers flock to online methods and digital data collection. In addition, research which engages communities and works with participants as co-investigators is seen as a powerful and emancipatory approach. A method gaining popularity is PhotoVoice that asks participants to share their lived experience through photography. We should also follow with interest the progress of rapid approaches to qualitative research. Rapid approaches can be useful for time sensitive projects but are not without their critics. Furthermore, as the qualitative evidence base grows so does the opportunity to conduct systematic reviews of qualitative evidence, qualitative evidence synthesis, and meta-synthesis (a somewhat distant cousin of meta-analysis). These are increasingly contributing to recommendations from the World Health Organization and other practice guidelines answering questions that go beyond feasibility and acceptability. For an example of a recent meta-synthesis see Whiffin et al. that examined the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period. This was a complex, and lengthy study. In contrast, in the context of the current pandemic a rapid approach to qualitative evidence synthesis enabled Houghton et al. to quickly influence policy and practice regarding adherence to infection prevention and control guidelines.

Recommendations

To aid neurosurgeons to conduct qualitative research we offer a number of recommendations and practical solutions (Box 1). In addition to these, we also recommend scoping review is conducted to understand more fully the contribution of qualitative research to the neurosurgical evidence base.

Conclusions

There is enormous potential for qualitative research to contribute to the advancement of patient care within neurosurgery. There are signs that more qualitative research is being conducted and published. However, we must improve knowledge and increase understanding of the quality in qualitative inquiry. Furthermore, while studies that pay little attention to the interpretive lens in qualitative research make an important contribution to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.

CRediT authorship contribution statement

Charlotte J. Whiffin: Conceptualization, Writing – original draft. Brandon G. Smith: Conceptualization, Writing – review & editing. Santhani M. Selveindran: Conceptualization, Writing – review & editing. Tom Bashford: Writing – review & editing. Ignatius N. Esene: Writing – review & editing. Harry Mee: Writing – review & editing. M. Tariq Barki: Writing – review & editing. Ronnie E. Baticulon: Writing – review & editing. Kathleen J. Khu: Writing – review & editing. Peter J. Hutchinson: Writing – review & editing. Angelos G. Kolias: Writing – review & editing.

• Design studies that are inclusive of qualitative methods to advance understanding of patient perspectives during quantitative studies such as clinical trials.

• Develop standalone qualitative studies that are not framed within a quantitative investigation and commit to in-depth, interpretive, exploratory analysis and the time this requires.

• Ask more complex qualitative research questions and embrace more advanced qualitative methodologies.

• Discuss qualitative research with others, talk about methods and methodology, reflect on the strengths and limitations of different approaches.

• Consult a qualitative expert for guidance, advice, and mentorship.

• Visit neuroqual.org for open-access qualitative resources for neurosurgeons and neurosurgery developed by members of the National Institute for Health Research (NIHR) Global Health Research Group on Neurotrauma and follow up-dates on Twitter (@Neuro_Qual) and LinkedIn (@Neuroqual).