Guide to Statistics and Methods 

Surgical Education Research

January 3, 2024

Practical Guide to Qualitative Research in Surgical Education

Gurjit Sandhu, Amy H. Kaji, Amalia Cochran

JAMA Surg. Published online January 3, 2024. doi:10.1001/jamasurg.2023.6681

Introduction

How do residents perceive and experience processes of remediation? What are the vicarious effects of surgical training on family and friends who support residents? How do women surgeons experience interprofessional workplace conflict? How do surgeons experience stress in the operating room?

These questions illustrate important surgical investigations that have been explored using qualitative research. Qualitative methods are particularly useful for exploratory studies that use how, what, and why questions, which aim to better understand social phenomena, group interactions, lived experiences, perspectives, attitudes, motivations, and beliefs of the people involved. In surgical education, qualitative research can be used to gain insight, locally and globally, into the experiences and perspectives of surgical residents, practicing surgeons, patients, operative teams, family members, and other stakeholders in the surgical education process.¹

Greater awareness of the different insights provided by qualitative investigations merits both invitation and increase in the quantity and quality of qualitative studies published in surgical journals.² The precis provided in this practical guide introduces the selection and application of qualitative research in surgical education.

Using the Methodology

Qualitative research methods are particularly useful for gaining in-depth understanding of events, experiences, and interactions. Quantitative methods unto themselves can be insufficient for studying complex and nuanced phenomena that are situated in particular contexts, cultures, places, and time. Rather than testing a hypothesis, qualitative research is hypothesis generating—which begins with exploring and describing patterns in data. The identified relationships can then inform development of quantitative questions to investigate issues that are inadequately studied (eg, surgeons and pregnancy), sensitive (eg, incivility), or socially complex (eg, reporting of duty hours). Often data generated from smaller groups of participants can support a conclusion; thus, clarifying when and why qualitative methods are being used is important for the research team, reviewers, and readers.^3-5

To use qualitative research effectively in surgical education, the following steps are suggested:

1. Use one of the Enhancing the Quality and Transparency of Health Research (EQUATOR) reporting guidelines for qualitative research, eg, Standards for Reporting Qualitative Research (SRQR), Enhancing the Transparency in the Reporting of Qualitative Health Research (ENTREQ), or Consolidated Criteria for Reporting Qualitative Studies (COREQ).⁶
2. Identify which phenomenon, event, experience, or voice you would like to describe or better understand. Why is this important to you?
3. Review the current state of published work on the topic of interest to describe what is known on the topic, identify knowledge gaps, and justify your research.
4. Include a team member with qualitative research expertise from the inception of the study. The rigor brought by a qualitative researcher during each step can bring awareness to resources essential to qualitative research, such as the time it takes to conduct a study, recruitment of participants, engaging experienced interviewers, transcription, software, and ethical considerations.
5. Establish a clear research question that will guide the direction of the study.
6. Determine the theoretical framework and research design that will underpin the study. Some common designs include the following⁷:
   • Action research—collaborating with research participants to advocate for social change
   • Case study—detailed investigation of a phenomenon in a bounded system
   • Discourse analysis—studying the underlying meaning of written texts or spoken language
   • Ethnography—studying behaviors, social interactions, rituals, and culture of communities
   • Grounded theory—producing a theory informed by participant experiences
   • Phenomenology—understanding the essence of a commonly lived experience
7. Determine appropriate sample size, how participants will be selected (eg, purposive, convenience) and approached, and anticipate reasons and numbers for refusal of participation. Ensure that participants represent the diversity of the population of interest. If textual or visual data are being used, describe the sources for that data (eg, policies, social media).
8. Determine the setting and data collection method, such as interviews, focus groups, observations, curricula, social media posts, photography, interview guide, transcripts, and journey mapping among others.
9. Analyze the data you have collected to identify patterns, themes, and relationships and describe details about the coding tree (if used), the number of coders, whether the themes identified a priori or were derived from the data, and the software used. Include transparent description of the analysis to provide assurance for how information power or saturation were achieved such that additional data collection would be redundant.
10. Report your findings clearly in a way that is concise and easy to understand (eg, quotations delineating major themes).

Advantages of using qualitative research in surgical education include acquiring deeper understanding into the experiences and perspectives of stakeholders, the ability to uncover complex and nuanced relationships, an opportunity for a diversity of voices to be heard through the research process, and generating new theories to be tested with quantitative research. There are also limitations associated with qualitative research in surgical education. These include the commitment of greater time and resources to data collect, analyzing the volume of data, and limited funding.

Statistical Considerations

Although quantitative data may be included in qualitative research (eg, descriptive statistics of participant demographics, Cohen κ for agreement between coders), they are not the basis for quality and rigor in qualitative research. Trustworthiness of qualitative research can be established using several strategies: credibility, reflexivity, dependability, confirmability, and transferability. It is important to bake trustworthiness into the design of the study and describe which criteria were integrated. Trustworthiness criteria include the following⁸:

1. Credibility and reflexivity—describing the credentials of interviewers, researchers, and coders and preexisting relationships between interviewer and participant provides insights into how beliefs, assumptions and biases were accounted for and managed in the research process.
2. Dependability—multiple researchers engaged in rigorous process for study design (sampling, participation and nonparticipation, information redundancy) and analysis (resolving discrepancies among coders or considering interrater reliability where appropriate, the coding tree, derivation of themes).
3. Confirmability—transparency in the process for data collection, steps for analysis, and interpretation (transcripts returned to participants for comment and correction and consistency between data and findings).
4. Transferability—clear and detailed descriptions of the study so that others can determine applicability to their setting.

The small size of a study population, sensitivity of research topics, and rigor of trustworthiness criteria require heightened awareness to ethical considerations; surgical education must mindfully navigate structures of hierarchy and vulnerability of participants. Approaches to mitigating ethical concerns include the following: reviewing consent intermittently with participants, member-checking by asking participant feedback on findings, deidentification and anonymity practices, anticipating and being prepared to provide resources and referrals to participants, and building research teams to include a diversity of experiences and expertise.

In this practical guide to qualitative research in surgical education, we have introduced methods, approaches to enhance quality and rigor, and a cautionary note for ethical consideration (Box). We hope this overview provides initial steps toward designing qualitative studies that can provide new and important insights in surgical education.

Box. 

Summary

1. Qualitative research is hypothesis generating.
2. Develop a research question and determine appropriateness of qualitative methods.
3. Include a team member with qualitative research expertise from the very inception of the study to direct you to the correct approach, avoiding sampling bias, assuring reflexivity, using rigorous analytic techniques, and consistency of data and findings, as well as applicability to target audience.

Where to Find More Information

• Additional resources for qualitative research in surgical education include:

1. Baker C, Knepil G, Courtney P. The role of qualitative research in oral and maxillofacial surgery. Br J Oral Maxillofac Surg. 2022 Sep 1;60(7):910-4.
2. Cristancho SM, Goldszmidt M, Lingard L, Watling C. Qualitative research essentials for medical education. Singapore Med J. 2018;59(12):622.
3. Equator Network. Enhancing the quality and transparency of health research.⁶
4. Sargeant J. Qualitative research part II: Participants, analysis, and quality assurance. J Grad Med Educ. 2012 Mar;4(1):1-3.
5. Shauver M, Chung K. A Guide to Qualitative Research in Plastic Surgery. Plast Reconstr Surg. 2010;126(3):1089-1097.
6. Sinyard, RD, Anteby R, Axelsson CGS, Healy MG, Ellison HB. Reviewing Qualitative Research in Surgical Education Literature. American College of Surgeons; 2021.⁹