Implementation of Constructivist Grounded Theory Methodology in Obesity Research

Implementation of Constructivist Grounded Theory Methodology in Obesity Research

To be an intuitive and curious individual with the ambition to ask questions and explore phenomena is a very powerful skill-set to possess in the nursing profession. Research has proven to be an invaluable tool in the advancement of knowledge, skills, and ultimately, the care of clients and patients. As nursing researchers, it becomes crucial to recognize and distinguish when and how to utilize this tool in its various forms. There is a prominence of quantitative research and demand for numerical data in healthcare today and understandably so, as it allows us to yield valuable information for evidence-based practice. However, with the increasing emphasis on patient-centered and holistic care, qualitative research has established itself on a pedestal of equal importance. Throughout this paper, the qualitative methodology of grounded theory (GT) will be explored with a concentration on one of its derivatives, the constructivist grounded theory (CGT). The intention is to begin to apply this theory and defend its relevancy to a phenomenon in obesity research.

Background of the Research Phenomenon

In the initial paper, “The Process of Formulating and Articulating a Qualitative Research Question” (Loria, 2018), I describe my clinical practice and the experiences that have led me to the start of my qualitative research journey. Obesity has become a worldwide epidemic that impacts individuals across the lifespan, and it has the potential to contribute to a myriad of other diseases. The current acute care system is overwhelmed with patients experiencing exacerbations of their chronic disease conditions. This global epidemic will continue to worsen if there is not quick and effective action taken at the root of the problem. Primary care is patients’ initial contact with the health care system, and health care providers in this sector play a major role in the treatment of these patients. When compared with quantitative research, the volume of qualitative research in obesity care and management is lacking. This fact is concerning given that qualitative research has proved essential in illuminating and understanding both patients’ and clinicians’ decision making as well as enhancing the appropriateness and quality of care being provided (Perez & Ball, 2015).

An ideal clinician-patient relationship is based upon a mutual and therapeutic exchange that allows for nursing and patient needs to be met adequately. However, lines in this relationship can become blurred. Practitioners may impose their clinical knowledge and expertise on patients without genuinely listening to what their needs are, but highly individualized care begins with the attempt to listen and understand. On the other hand, practitioners undoubtedly face many challenges in working with particular populations (e.g., obese families) and perhaps feel that their clinical capabilities and knowledge are not received nor valued by the clients under their care. That said, the phenomenon I seek to explore is the perspectives of primary health care providers and the factors they perceive to promote or inhibit obese families to engage in healthy lifestyle behaviors. In order to achieve substantial depth in the collected data, it is ideal to interview both entities in this relationship. Due to ethical constraints of this course, only primary health care practitioners will be elicited for interviews. “By engaging frontline personnel as key informants within the context of this question, I hope to gain insight on the meaning and experiences of implementing care to the obese population by primary care providers. The aim is to shed light on the challenges and successes faced in daily practice with this population and explore the participants’ perceived accomplishments and failures in providing care and interventions for these patients” (Loria, 2018, p.7). Studying the dynamics of this relationship may bring further insight on how to care for this population and hopefully contribute to deescalating an epidemic that is currently out of control.   

Choosing a Research Design and Methodology

Questioning and researching phenomena is crucial to the advancement of any profession. However, producing excellent results is highly dependent on the ability to choose the most appropriate research methodology for the type of information that is sought. “The research design needs to be appropriate and depends entirely on the chosen topic and research question” (Holloway & Galvin, 2017, p.35). Furthermore, Birks and Mills (2015) define a methodology as a set of principles and ideas that inform the design of a research study and stems from a congruent philosophy. Researchers need to be cognizant of how they position themselves philosophically, both ontologically and epistemologically. Chosen research methodologies should align with the researcher’s perception of reality and knowledge as they influence every part of the research process (Mills, Bonner, & Francis, 2006b). “Each of us has a unique conceptualization of existence and reality. How we understand the world is influenced by our history and the context in which we find ourselves. Our philosophy defines what we consider to be real and how we can legitimately acquire knowledge about the world” (Birks & Mills, 2015, p.1). Different focuses of research may arise from a variety of different sources (e.g., experiences) but how we formulate and explore questions is based on the researcher’s notions regarding the nature of reality, how the knower and what can be known are related, and how to best discover reality (Annells, 1996).

There are multiple qualitative research methodologies, and although similar in some ways, each one possesses distinct characteristics and an ultimate goal that differentiates them from the rest. In addition to purpose, the appropriate methodological choice takes in to account the role of the researcher, the data collected, the method of data analysis, and how the results are presented. In order to choose the most appropriate design for my research inquiry, I had to reflect on my philosophical views, the type of question I am asking, and the information that I seek. “I do not wish to hypothesize but to discover. I believe in the existence of multiple realities that are context-driven, and it is imperative to understand and respect that experience is individualized. I am interested in the subjective experiences of participants and the meaning they attribute to what happens in their daily lives. I am also keen to discover ideas, beliefs, values, and other intangibles” (Loria, 2018, p.5). While utilizing a philosophical lens, the objective of my research is to expose concepts and develop theories as they are related to my phenomenon of interest. In saying this, I have been drawn to the GT methodology, specifically from a constructivist perspective.
Grounded Theory
Barney G. Glaser and Anselm L. Strauss were two prominent American sociologists of the 1960’s and are considered the fathers of GT development. Both men recognized that there was an overemphasis on the verification of theories and not enough emphasis on the generation of theories. During the early days of GT development, quantitative data and positivist paradigms were dominant forces in many professional arenas. “Mid-century positivistic conceptions of the scientific method and knowledge stressed objectivity, generality, replication of research, and falsification of competing hypotheses and theories” (Charmaz, 2014, p.6). Demands for qualitative data regarding human problems and experiences was scarce, and positivists rejected interpretive and intuitive ways of knowing outside of the empirical paradigm. Logical and deductive hypotheses and research aimed to confirm or refine existent theory but rarely generated it. Glaser and Strauss attempted to bridge the gap between theory and empiricism by blending theory construction and social research; they believed this would be more successful than theories logically deduced from a priori assumptions (Glaser & Strauss, 1967; Kenny & Fourie, 2014).

Grounded theory investigates the actualities in the real world and analyzes the data while aiming to be explanatory rather than descriptive. Researcher’s start with an area of interest, collect and an analyze data while allowing relevant ideas to develop (Holloway & Galvin, 2017). A traditional GT approach is an iterative and systematic process involving manual coding, categorizing, and comparing data; there is emphasis that preconceived methods, theories, conceptions, or assumptions are avoided (Glaser & Strauss, 1967). Furthermore, in a keynote address by Glaser (1999), he states that to be an effective grounded theory researcher, one must be able to tolerate confusion and regression. To be aware and open to the unexpected is crucial, as there are no distinct answers and every question generates the potential for discoveries.

The GT research process involves progressively identifying, refining and integrating categories, which eventually contribute to theory as the end product (Willig, 2013). Grounded theory utilizes both inductive and deductive modes of inquiry, with the latter more prominent as the research continues. Initially, an inductive approach is used to gather and compare data, discover patterns, and with a developing theory, a deductive approach leads to more focused data collection. The finished product of this type of research is termed grounded theory as the developed theory is directly based and “grounded” in the data collected (Holloway & Galvin, 2017). The researcher immerses themselves in the data, and this allows them to provide a ‘thick description’ of the data (McCann & Clark, 2003).

As time passed, Glaser and Strauss found that they had differing opinions on critical theoretical and philosophical assumptions of the original GT approach, resulting in the creation of two different paradigms. The first being a positivist Glaserian style of GT (Glaser, 1992) which stresses that the theory emerges from the data rather than using specific pre-set categories. The second type was developed when Anselm Strauss joined forces with fellow sociologist Juliet Corbin to construct what is known as the Straussian style of GT (Strauss & Corbin, 1990); a relativist perspective that emphasizes a systematic design with data analysis and coding existing in steps. To advance GT methodology one step further, during the 2000s Kathy Charmaz, a former student of Barney Glaser, was the first researcher to label her work as constructivist grounded theory.

It is essential for any GT researcher to understand the evolution of the GT methodology, as well as the characteristics that both relate and distinguish the three different versions from one another. Santos et al. (2018) describe the three main methodological perspectives of GT as having four common characteristics including their use of theoretical sampling, constant comparative analysis of data, utilization of memos, and variance between substantive and formal theories. Contrarily, the three characteristics that differentiate each branch include their philosophical basis, use of existing literature, and the system they use to analyze the collected data (Santos et al., 2018). All of the preceding characteristics are discussed in the following paragraphs; however, for those characteristics that are dissimilar between the methodologies, a focus is placed on my methodological preference, Kathy Charmaz’s CGT.

Symbolic Interactionism

Barney Glaser and Anselm Strauss did not initially discuss a philosophical base or theoretical framework for their proposed GT methodology (Holloway & Galvin, 2017), but is labeled as positivist due to its emphasis objectivity and neutrality in theory development (Santos et al., 2018). However, symbolic interactionism, an interpretivist methodology, was labeled as having a strong link to grounded theory in the Strauss, Corbin, and Charmaz eras. In symbolic interactionism individual definitions of reality are derived cultural and social interactions; these experiences not only shape perceptions, actions, and behaviors, but factors such as relationships with others and expectations of society influence them (Holloway & Galvin, 2017).

A Focus On Constructivist Grounded Theory

“The methodological framework with its underpinning philosophy influences how the researcher works with the participants, in other words, the position they take in the study. Depending on their philosophical beliefs and adopted methodology, researcher’s take either a position of distance or acknowledged inclusion in both the field and in the final product of the study” (Birks & Mills, 2015, p.4). Classical GT takes on a traditional role of the researcher as an objective observer, while undertaking a constructivist inquiry requires the adoption of mutuality between researcher and participant in the research process (Mills, Bonner, & Francis, 2006a). I deeply value the principles of classical GT, but I am drawn to the consideration that CGT provides to the researcher, who is vital to the research process. Guba and Lincoln (1994) described constructivism as the perception of the nature of reality that is mentally constructed by one person (relativism) and dependent on social, political, cultural, economic, ethnic, and gender factors that differentiate the interpreters. There are as many realities as there are people and individual constructions are subject to continuous revision. There is a subjective and interactive connection between the knower and what is known.  “The main idea behind constructivism it is that knowledge is socially constructed in relationships with others and cannot be separated from that relationship. In other words, relationships influence one another and impact the development of knowledge” (S. Raffin-Bouchal, personal communication, October 15, 2018).

Kathy Charmaz recognized the researcher’s relationship with the researched is one of mutuality and is a privileged connection that the researcher must identify and respect (Gardner, McCutcheon, & Fedoruk, 2012). I believe that the researcher and the researched can never truly be independent of one another; for researchers to be completely objective is impossible. “Constructivist grounded theory reshapes the interactive relationship between researchers and participants in the research process and provides the reader with a sense of the analytical lenses through which the researcher observes the data” (Ghezeljeh & Emami, 2009). Charmaz refined the assumptions of Glaser and Strauss’ original positivist grounded theory to reflect more of a relativist view that participants, as well as researcher’s, are affected by lifelong interactions with people, places, education, opinions, and so on. (Higginbottom & Lauridsen, 2014). Constructivists believe that reality is shaped and invented in our minds on an individual basis. There is not one reality, there are multiple “realities,” and collecting and analyzing data require capturing and taking into account those multiple viewpoints. Ontologically, constructivist grounded theorists encourage that social realities are inseparable from the researcher as they construct the worlds they research. We create knowledge through subjective interpretations of their surroundings and relationships. Reality and truth are understood within a broad framework, positioned within a certain time, place, and culture (Charmaz, 2006). From an epistemological standpoint, knowledge is created through the interaction between the researcher and the researched. The constructivist approach assumes that there are interrelationships between participants and researcher’s and thus they co-construct the realities they share. “The constructivist investigation starts from the experience and inquires about how participants created it; thereby, both researcher and participant interpret the meanings and actions of this experience” (Crossetti, Goes, & de Brum, 2015, p.48). Constructivist grounded researchers recognize that they generate and construct theories from the observations they make, which is inevitably influenced by their perception and interpretation of reality. “We construct our theories through our past and present interactions with people, perspectives, and research practices” (Gardner, McCutcheon, & Fedoruk, 2012, p.69). Data collection, analysis, interpretation, and dissemination are all performed by the researcher and coloured with their perceptions, beliefs, values, and ideas. However, it is important to note, Charmaz encourages researcher’s to check how participants’ make sense of both theirs and the researcher’s interpretations (Sing & Estefan, 2018). This notion of doing with is essential to both the nursing profession as well as research.

As novice qualitative researchers, we are taught the importance of incorporating reflexivity into our research. Holloway and Galvin (2017) define reflexivity as a “conscious attempt by the researcher to acknowledge their involvement in the study” (p.9). Researchers must remain self-aware of how their interactions with participants as well as their innate thoughts, opinions, values, feelings and even mere presence, may impact findings and eventual study outcomes. “Using a constructivist approach to research fosters reflexivity on behalf of the researcher culminating in the co-construction of a theory that is a combination of the researcher and the participants stores and views (Gardner, McCutcheon, & Fedoruk, 2012).

Effective (Constructivist) Grounded Theory Research

Conducting an effective GT study that is both reliable and rigorous requires constant awareness by the researcher that they are adhering to the common traditions of GT framework. Furthermore, they need to remain open to allow the information to develop organically. The idea that “everything is data” allows for the collection of both formal and informal data, which are invaluable to data collection as they capture a natural and realistic lens. From the beginning to end of a GT research project, there is a constant interplay, between gathering and analyzing data. The aspects of immediate data analysis and constant comparison throughout the study ensure that researchers remain engaged; further explorations of certain data and relationships between data are not missed. “It enables the researcher to identify similarities and differences in the data and informs further data collection” (Engward, 2013). Early analytic work expedites progress towards the destination and also provides an element of excitement for the researcher about the process and product (Charmaz, 2014).

Theoretical sampling is a result of the constant comparative analysis of data that occurs within GT research. Data collection and analysis are an iterative process and sampling is targeted as the study evolves, concepts emerge, and new information is needed. “The researcher strategically decides about what or who will provide the most information-rich source of data to meet their analytical needs” (Birks & Mills, 2015). Practicing theoretical sensitivity is a concept that is personal and individualized. It is based on the researchers past knowledge and experiences and how that influences their everyday thoughts. In opposition to classical grounded theorists who would say this would influence data, CGT utilizes theoretical sensitivity as a tool to draw on in the act of theory development (Mills, Bonner, & Francis, 2006). “As grounded theorists become immersed in the data, their level of theoretical sensitivity to analytical possibilities will increase” (Birks & Mills, 2015).

Continuous comparative analysis, contrasting, and coding of the data is fundamental to GT methodology. As data is collected from interviews, focus groups, observations, and so on, it is meticulously analyzed word-by-word or line-by-line to generate conceptual codes, explained further below. Memos are a substantial element in the GT process and take the form of “preliminary anecdotal notes” (Charmaz, 2014). Memos allow the researcher to express their ideas, thoughts, and questions as data emerges from interactions. Participating in writing memos throughout the research process provides the researcher with the opportunity to be active in the process and freedom to re-explore areas that are unclear or can be explored further. In the same sense, keeping memos provides the opportunity to maintain awareness of common themes and alerts when saturation has occurred. Memos help build the categories that will make up the central category (Crosetti, Goes, & de Brum, 2016).

Coding is the pivotal link between collecting data and developing an emergent theory to explain these data. During coding, labels are attached to segments of data to describe what each segment is about. From here, analytic questions can be raised about the data from the very beginning of data collection” (Charmaz, 2006; Charmaz, 2014). There are different levels of coding in GT methodology and relates to the transition between inductive and deductive reasoning alluded to earlier in this paper; however, the constructivist GT method focuses specifically on initial (open) and focused coding. Open coding generates as many ideas as possible from early data and is exemplary of an inductive approach. Codes called “in-vivo” codes come directly from participants and can give life and interest to the study as well as immediately recognized as reflecting the reality of the participants (Holloway & Galvin, 2017). This initial level of coding is fluid and adaptable, yet progressive, as it provides researchers a direction for data collection. Charmaz’s style of coding offers a more interpretive, intuitive, and impressionistic feel (Charmaz, 2006). Coding becomes more focused or deductive as data collection and analysis are continued, and the most prevalent of the open codes are decided as contributing most to the analysis. Focused coding takes place, where elaborate codes are targeted, selective, and conceptual as they should synthesize and explain larger data segments. Prominent concepts emerge while categories and subcategories are created, this in turn, exposes a central phenomenon or category interpreted and disseminated according to the researcher’s perception (Santos et al., 2018). The final phase in grounded theory is the production of either a formal or a substantive theory. “Formal theories are more general and deal with a conceptual area of enquiry. Substantive theories, which are more common, focus on specific social processes and are developed from narrower areas of study (McCann & Clark, 2003, p.9). Formal theories are the building blocks for formal theories (Santos et al., 2018). Data saturation in GT methodology occurs when all of the concepts in the theory being developed are understood and can be validated in the data (Engward, 2013). No new categories can be identified, and new variations in the existing categories have ceased to emerge (A.L. Ferguson, personal communication, October 1, 2018).

When and how to incorporate existing literature into the research project is debatable between GT methodologies but is typically used as a comparative tool. Charmaz (2006) suggests that existing literature should be utilized throughout the entire piece as well as compiled into an exclusive literature review. In order to avoid becoming too immersed in the literature or influenced by it, she suggests avoiding compilation of a literature review until after data analysis is complete. This allows the researcher to enter into the dialogue in the academic field, reinforces the researcher’s findings as credible, and justifies rationale (Charmaz, 2006). According to Charmaz (2014), an effective grounded theory study should be credible, original, resonant, and useful. In other words, there is enough evidence to support claims and for readers to develop their own opinions; there are new conceptual interpretations of the focus of the work, informants confirm the data as reasonable while providing them with deeper insight into their worlds, and interpretations can be utilized in daily practice.

My Research Using Constructivist Grounded Theory

Through learning and discovery of other qualitative research methods, I believe that CGT has spoken to me most as a nurse, a researcher, and a human being. I recognize every person as an individual entity with a unique story, which has been shaped by a lifetime of experiences and interactions with the world around them. When any of us engage in relationships in the various settings of our lives, we bring a lens of individuality. “A grounded theory approach provides nursing with a feasible means of generating theory about dominant psychosocial processes that present with­in human interactions, a theory that is grounded in the realities of everyday clinical practice” (Mediani, 2017, p.3)

Weight loss for those who are overweight or obese is a challenging feat to undertake and is influenced by a plethora of powerful factors. In the same sense, providing guidance and care for these patients when truly invested in their health, can pose similar challenges. The GT method aims to capture social processes in social settings and it is useful when the goal is a framework or theory that explains human behavior in a context (Mediani, 2017). Obesity and the patient-client relationship are heavily rooted in a social context and therefore, employing a grounded theory technique may provide insight on patterns in these instances (Engward, 2013). My aim is not to describe these relationships but instead generate concepts that explain the experiences, actions, and behaviors within these relationships. “The premise of grounded theory is that enquiry should explore social phenomena by looking at what people experience, what problems are present, and how individuals go about resolving these issues” (Engward, 2013). As a health care provider, I find the principles of GT research humbling, as it challenges us to lose our “care provider knows best” attitude or the pressures of being in control. We become vulnerable to what we are investigating, and we allow it to speak to us rather than speak to it. We seek to discover what we do not know instead of trying to confirm what we already think we know. Constructivist grounded theory excels the original methodology to a level whereby it recognizes the role of the researcher as influential throughout the whole research process. The authentic experiences of obese clients and their corresponding healthcare providers can be articulated only by those immersed in the setting. “Entering the phenomenon shrinks the distance between the viewer and the viewed. Subsequently, we might better understand our research participants’ multiple realities and standpoints” (Charmaz, 2008, p. 133). The CGT methodology mirrors the reality of the nursing profession, especially the nurse-client relationship. It is a symbiotic and interdependent relationship, similar to the one that cultivates between a researcher and a participant.

Conclusion

Qualitative research is a type of inquiry, which seeks to explore, interpret, understand and provide insight into phenomena in natural settings. The choice of qualitative research methodology is crucial in shaping all aspects of the research process. The methodology must align with the philosophy or belief system of the researcher as well as the research question and the desired outcome (Teherani, Martimianakis, Stenfors-Hayes, Wadhwa, & Varpio, 2015). It is not only imperative for nurses to understand the subjective experiences, relationships, and social behaviors of their patients’ but also be able to articulate their perspectives on such. Grounded theory gives researchers the opportunity to examine these comprehensive phenomena without the restrictions of a preconceived framework and doors open to endless discovery and new explanations.

Human beings live in an ever-evolving and dynamic reality shaped by every component of their surroundings. When studying these realities and how they relate to one another, there is a significant interplay that occurs once we can appreciate the researcher’s reality as just as influential on the research process as any other. Constructivist grounded theory mirrors the traditional nurse-client relationship as it positions the researcher as participants’ partner in the research process, rather than objective analyst of subjects’ experiences (Mills, Bonner, & Francis, 2006a). By utilizing qualitative theories such as CGT in obesity research, it enables researchers’ and those who read their work to view the world through a unique lens that is rich and complex. To be an effective CGT researcher who creates work that demonstrates creativity and flexibility, yet remains rigorous, is a specialized skill to develop over time. Ultimately, the goal of any GT researcher is to construct and develop a valuable theoretical foundation to guide practice and aid in the evolution of knowledge in order to better serve the patient and clients whom we work with and care for on a daily basis.

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