Introduction

Grounded theory was developed by Barney Glaser and Anselm Strauss in the 1960s as a methodological approach for qualitative research.[1] Grounded theory is unique because it not merely about understanding a phenomenon but about generating new theories grounded in empirical data. This approach is useful in medical research where existing theories may be inadequate or where researchers often need to explore complex phenomena that are not well-understood.

Core Principles of Grounded Theory

Grounded theory involves systematic data collection and analysis with the goal of developing theories that are ‘grounded’ in the data itself. This involves three key principles:

• Inductive Reasoning: Grounded theory relies on inductive reasoning, where theories are developed based on patterns observed in the data rather than from pre-existing hypotheses.[2] This process ensures that the resulting theories are closely aligned with the participants’ experiences and the data’s nuances.

• Constant Comparative Method: A key feature of grounded theory is the constant comparative method, which involves comparing data with emerging categories throughout the research process. This process helps refine categories and develop a coherent theoretical framework by continually comparing new data with existing categories.[3]

• Theoretical Sampling: This is a process where data collection is guided by the emerging theory. Researchers select participants and data sources based on their relevance to the developing theoretical concepts.[4] This approach ensures that data collection is driven by theoretical insights rather than random sampling.

Use of Grounded Theory in Medical Health Research

Grounded theory has been widely applied in medical health research to explore complex, often under-studied phenomena. Its flexibility and depth make it particularly suited for understanding patients’ experiences, healthcare practices, and the dynamics of health interventions.

• Exploring Patient Experiences – Grounded theory has been used to gain insights into patients’ experiences with chronic illness, mental health, and healthcare systems. For example, a study by Lennox Thompson, Gage, and Kirk used grounded theory to explore the experiences of individuals with chronic pain, revealing how their illness narratives shaped their interactions with healthcare providers and their coping mechanisms. The study uncovered themes related to pain management strategies and the emotional impact of chronic pain, contributing to a deeper understanding of patient experiences and informing patient-centered care practices. [5]

• Understanding Healthcare Practices – Researchers have applied grounded theory to understand various aspects of healthcare practices, including clinician-patient interactions and the implementation of health policies. A study by Corbin and Strauss investigated how healthcare professionals adapt to new clinical guidelines and protocols, uncovering the challenges and strategies associated with integrating new practices into routine care. Their research revealed the challenges faced by professionals in integrating new practices into routine care and identified strategies for overcoming these barriers, providing valuable insights for improving healthcare delivery.[6]

• Developing Health Interventions – Grounded theory can also inform the development of health interventions by identifying factors that influence their effectiveness. For instance, a study by Mandlik, Oetzel, and Kadirov employed grounded theory to develop a new intervention for improving rates of obesity.[7]

Methodological Process to Grounded Theory

The process of conducting grounded theory research involves several phases:

1. Data Collection: Grounded theory research typically involves qualitative data collection methods such as interviews, focus groups, and observations. Glaser and Strauss (1967) emphasized the importance of flexibility in data collection, allowing researchers to adapt their approach based on emerging themes. For example, a study on patient experiences with telemedicine might use semi-structured interviews to gather detailed narratives from participants, enabling researchers to explore various aspects of their experiences and interactions with telemedicine.[8]

2. Coding and Categorization: Coding is a fundamental aspect of grounded theory analysis. Researchers begin with open coding, where they segment data into meaningful units and assign preliminary codes. Charmaz (2014) describes this process as crucial for identifying initial concepts and patterns in the data. As coding progresses, researchers move to axial coding, which involves relating codes to one another and developing categories that represent more abstract concepts.[9] Finally, selective coding involves integrating these categories to form a coherent theoretical framework. For instance, in a study on healthcare access among underserved populations, researchers might code data to identify themes related to barriers and facilitators of access and then integrate these themes to develop a comprehensive understanding of access issues.

3. Theoretical Sampling and Saturation: Theoretical sampling guides data collection based on the emerging theory, ensuring that new data sources contribute to refining and elaborating theoretical categories.[10] Saturation is the point at which no new information emerges from the data, and theoretical categories are well-developed. Achieving saturation is essential for ensuring that the theory is comprehensive and grounded in the data.[11] Researchers must carefully monitor the data collection process to ensure that saturation is reached and that the resulting theory accurately reflects the data.

Challenges to Grounded Theory

Grounded theory research presents several challenges that researchers must address to ensure the credibility and rigor of their findings:

1. Managing Subjectivity: One of the challenges in grounded theory research is managing researcher subjectivity and biases. Reflexivity, or the process of reflecting on how researchers’ backgrounds and perspectives influence the research, is crucial for maintaining objectivity.[12] Researchers should regularly engage in reflexive practices, such as maintaining a research diary and discussing insights with colleagues, to address potential biases and enhance the validity of their findings.

2. Ensuring Rigor and Validity: Rigor and validity are essential for producing credible grounded theory research. Researchers can enhance rigor by maintaining a clear audit trail, using multiple coders to ensure consistency in coding, and engaging in member checking to validate findings with participants.[13] An audit trail documents the research process and decisions, while multiple coders and member checking contribute to the credibility and trustworthiness of the findings.

3. Balancing Depth and Scope: Grounded theory research often involves a deep exploration of specific contexts or phenomena. Researchers must balance the depth of their analysis with the scope of their study to ensure that their findings are both comprehensive and relevant. For example, in a study on patient experiences with a new medication, researchers need to provide detailed insights into individual experiences while also identifying broader patterns applicable to the wider population.

Tips for Using Grounded Theory

To effectively apply grounded theory in medical health research, researchers should consider the following tips:

1. Engage with Existing Literature: While grounded theory focuses on generating new theories, engaging with existing literature can provide context and help identify gaps that the research can address. Understanding current theories and frameworks can inform the research design and data collection process.[14] Researchers should review relevant literature to ensure that their research contributes new insights and addresses existing gaps.

2. Foster Collaboration and Peer Review: Collaboration with colleagues and peer review can enhance the quality and credibility of grounded theory research. Discussing emerging themes and theories with peers provides valuable feedback and helps refine the analysis.[15] Researchers should seek input from colleagues and experts in the field to strengthen their research and ensure that their findings are robust and well-supported.

3. Maintain Flexibility: Grounded theory research requires flexibility in data collection and analysis. Researchers should be prepared to adapt their approach based on emerging findings and be open to revising their theoretical framework as new insights emerge.[16] Flexibility allows researchers to respond to the data dynamically and ensures that the resulting theory accurately reflects participants’ experiences and perspectives.

4. Document the Research Process: Maintaining detailed documentation of the research process is essential for transparency and replicability. Researchers should document data collection methods, coding decisions, and theoretical developments to support the credibility and rigor of their findings.[17] This documentation provides a clear record of the research process and helps ensure that the findings can be independently verified and replicated.

Conclusion

Grounded theory offers a powerful methodology for generating new theories and insights in medical and health research. By adhering to its core principles, employing systematic data collection and analysis, and addressing challenges related to subjectivity and rigor, researchers can leverage grounded theory to explore complex phenomena and develop meaningful theories. With its flexibility and depth, grounded theory provides a robust framework for advancing our understanding of medical and health-related issues, ultimately contributing to improved patient care and health outcomes.

Take Away

This article discusses the various ways that grounded theory can be used when conducting qualitative research in medical health settings.

[1] Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine Publishing.

[2] Bryant, A., & Charmaz, K. (2007). The SAGE handbook of grounded theory. Sage Publications.

[3] Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine Publishing.

[4] Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Sage Publications.

[5] Lennox Thompson, B., Gage, J., & Kirk, R. (2020). Living well with chronic pain: a classical grounded theory. Disability and rehabilitation, 42(8), 1141-1152.

[6] Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory (4th ed.). Sage Publications.

[7] Mandlik, M., Oetzel, J. G., & Kadirov, D. (2021). Obesity and health care interventions: Substantiating a multi‐modal challenge through the lens of grounded theory. Health Promotion Journal of Australia, 32(2), 274-284.

[8] Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Aldine Publishing.

[9] Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage Publications.

[10] Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Sage Publications.

[11] Morse, J. M. (2007). Sampling in grounded theory. In A. Bryant & K. Charmaz (Eds.), The SAGE handbook of grounded theory (pp. 229-244). Sage Publications.

[12] Finlay, L. (2002). “Outing” the researcher: The provenance, process, and practice of reflexivity. Qualitative Health Research, 12(4), 531-545. https://doi.org/10.1177/104973230201200401

[13] Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. M. (2016). Member checking: A tool to enhance trustworthiness or merely a formality? Qualitative Health Research, 26(13), 1802-1811. https://doi.org/10.1177/1049732316654870

[14] Sandelowski, M. (1993). Rigor or rigor mortis: The problem of rigor in qualitative research revisited. Advances in Nursing Science, 16(2), 1-8. https://doi.org/10.1097/00012272-199304000-00002

[15] Guba, E. G., & Lincoln, Y. S. (2005). Paradigmatic controversies, contradictions, and emerging confluences. In N. K. Denzin & Y. S. Lincoln (Eds.), The SAGE handbook of qualitative research (3rd ed., pp. 191-215). Sage Publications.

[16] Charmaz, K. (2014). Constructing grounded theory (2nd ed.). Sage Publications.

[17] Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verifying qualitative research findings by checking and rechecking. Qualitative Health Research, 12(2), 250-261. https://doi.org/10.1177/104973230201200206