Qualitative Articles Paper – nursing homework essays

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Qualitative Articles Paper. Nurs Midwifery Stud. 2017 June; 6(2):e38284. doi: 10.5812/nmsjournal.38284. Published online 2016 November 21. Review Article Issues of Theoretical Sampling: A Narrative Review Nayyereh Davoudi,1,2 Nahid Dehghan Nayeri,3,* Afsaneh Raiesifar,1 Sarieh Poortaghi,4 and Shamsi 5 Ahmadian 1 Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran Department of Medical Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, IR Iran Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran 4 Department of Community Health Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran 5 Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, IR Iran 2 3 * Corresponding author: Nahid Dehghan Nayeri, Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2166914368, Fax: +98-2161054170, E-mail: nahid.nayeri@gmail.com Received 2016 April 06; Revised 2016 November 01; Accepted 2016 November 12. Abstract Context: Theoretical sampling is the hallmark of grounded theory methodology, but there seems to be little information accessible to researchers regarding process and guidance concerning theoretical sampling. The current study aimed to have a comprehensive and thorough review of the related studies on theoretical sampling and examine definitions, challenges, differences and applicable tips about this type of sampling to provide a comprehensive and clear picture of the sampling process and its probable challenges as well as explaining its practical aspects. Objectives: The ultimate goal of all the explorations is to provide practical sources for researchers to answer their questions about theoretical sampling. Data Sources: Databases such as ProQuest, Scopus, Pubmed, Science Direct, Wiley, Ovid, Google Scholar, and also Magiran, SID and Iran Medex (Persian databases) were searched from 1967 to 2015 using keywords of theoretical sampling and qualitative sampling. Study Selection: A total of 562 Persian and English studies were found. According to the inclusion and exclusion criteria thirty articles and nine books were examined thoroughly. Data Extraction: The narrative literature review was used as the most appropriate method to manage the data. Qualitative Articles Paper

Results: Definitions and characteristics of theoretical sampling; theoretical sampling of data archive; the difference between theoretical, purposeful and selective sampling; saturation and credibility in theoretical sampling were discussed in results. Conclusions: The current study indicated disagreements about some theoretical definitions and operational applications of theoretical sampling; however, the general consensus was that researchers explicated the decision making process in detail. Researchers should justify the selection and the sequence of sampling process to explain the complicated process of analytical abstraction and theory development by empirical data. Hence, the credibility of their theory and research is enhanced. Keywords: Theoretical Sampling, Qualitative Sampling, Qualitative Research, Qualitative Method, Grounded Theory 1. Context Human beings are complicated and partly unpredictable. Their individual differences and special needs make it impossible to form a universal law of human behavior. Qualitative researchers emphasize the importance of detailed and exact description of social actions. They attempt to understand how participants experience their world. To explicate the individuals’ experiences, researchers try to present a thorough understanding of human behaviors (1), and create a word picture of today’s multi-faceted and complex life. To this end, qualitative data collection should be thorough to answer the research questions in depth (2). There are some similarities in qualitative paradigms, although sampling and qualitative data analysis involve a wide range of research traditions and techniques. Qualita- tive sampling is naturalistic since it is done in normal and natural and not artificial situations (3). Qualitative sampling is based upon context which means it considers individual’s characteristics, the effect of time, location and situation (4). Sampling is therefore the key element of qualitative research (1, 5) and determines the quality of a qualitative research (6). As Patton noted, selecting participants should be congruent with the research conceptual framework. In other words, which and how many participants relate to what researcher strives to know, what the research purpose is, what proves useful and what has credibility (7), all should be taken into account. The sampling method in qualitative research is also determined by methodological procedures. The qualitative research in health sciences is typically focused on grounded theory, phenomenology and ethnography (8). Among them, grounded theory is one of the most popu- Copyright © 2016, Kashan University of Medical Sciences. Qualitative Articles Paper

Qualitative Articles Paper. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. Davoudi N et al. lar and common qualitative research methods (9). This general methodology attempts to develop a theory that is ‘grounded’ in the data from which it is derived. Therefore, sampling in grounded theory is directed toward producing and developing an emerging conceptual theory (10). Reviewing recent qualitative studies indicates that despite most writers’ agreement on definition of theoretical sampling, its process remains largely vague and contradictory. Therefore, employing theoretical sampling can lead to specific challenges for novice researchers who are conducting their first grounded theory study (10). Draucker et al. reported that despite the fact that theoretical sampling is the hallmark of grounded theory, there is little practical guidance accessible to researchers regarding the process of theoretical sampling. The reason is that the researchers who used this method provided little descriptions on how they applied the sampling in response to the emergent findings (11). For example, in the studies conducted by Vandecasteele et al. and Ward et al. the processes of theoretical sampling were not explained, and if yet so, researchers used different interpretations of theoretical sampling and its application method (12, 13). Also, in two recent grounded theory studies, Moudi et al. and Mirzaee Rabor et al. used purposive sampling to select the study participants; however, they did not mention the employment of theoretical sampling in their studies (14, 15). In the study by Masoudi Alavi et al. through grounded theory, some sentences showed that selecting participants during the study was merely purposive and was not theoretical. For example they said that: “the participant selection process deliberately selected patients at different ages and with various physical conditions” or “after collecting data from the patient group, fifteen health professionals with at least five years of experience working with persons with diabetes were selected” (16). In another grounded theory study, although researchers did not mention the employment of theoretical sampling, it seems that this approach was used to select participants along with the progress of the study (17). Hence, the current study aimed to have a comprehensive review of related studies on theoretical sampling and examine definitions, challenges, differences and applicable tips about this type of sampling to provide a comprehensive and clear picture of the sampling process and its probable challenges as well as explaining its practical aspects. 2. Objectives The ultimate goal was to provide a practical source to answer the questions during their qualitative researches. Qualitative Articles Paper

Qualitative Articles Paper. 2 Accordingly, the current study major questions were as follows: – How is theoretical sampling defined? And what are its specific characteristics? – What are the practical phases of theoretical sampling? – What are the issues of its applications? And what are the strategies to confront these issues in practice? 3. Data Sources In the current study, relevant databases were searched to find appropriate resources and studies. Databases such as Science Direct, Pubmed, Scopus, ProQuest, Google Scholar, Ovid, and Wiley were searched to examine published studies. Keyword of theoretical sampling and qualitative sampling were searched. To achieve a wide range of studies and not missing related studies, AND/OR operators were not used while searching and the keywords of theoretical sampling and qualitative sampling were not put into the brackets. Furthermore, the search in the databases was not confined to only review articles, since by doing so there was the possibility of missing some of the studies. 4. Study Selection The criteria for inclusion in the study were as follows: – Keywords in the title of articles: considering the aim of study, keywords were searched in the title of articles (not in the abstracts); therefore, the researcher can access theoretical articles rather than methodological ones about the concept under study. – To be published from 1967 to 2015 (history of theoretical sampling refers to the simultaneous discovery of grounded theory by Glaser and Strauss in 1967. The reason for the selection of this time period was the ability of researchers to have a comprehensive review for definitions, challenges of theoretical sampling from its emergence up to now as well as to clarify and monitor them in case of any changes in the traits). The exclusion criteria were also as follows: Being Ebooks; not being in English or Persian; not being relevant to the aims of the study, being duplicated; and full text not accessible. Hence, the process for the selection of articles was based on this protocol: A) Assessing the relationship of title to the goals of the study; B) Examining the relationship of abstract to the aims of the study and C) Exploring full text (in case of availability) according to its consistency with the aims of the study. In addition to searching the databases, all relevant books accessible to the researchers in the library of school of nursing and midwifery in Tehran University of Medical Nurs Midwifery Stud. 2017; 6(2):e38284. Davoudi N et al. Sciences were also included in the study. Flowchart of the review process is presented in Figure 1. 5. Data Extraction The narrative literature review was used as the most appropriate method for the study. This type of review article tries to summarize a huge volume of information in a specific field and provide findings in a clear and explicit manner (18). Review of studies using narrative method can cover a wide range of topics in various levels in a comprehensive way. Qualitative Articles Paper

The method can either undergo a comprehensive searching or not, and quality assessment of articles can either be done or not. Synthesis in such studies is generally narrative and analysis may be chronological, conceptual or thematic (19). 6. Results It seems vital to note differences between quantitative and qualitative sampling as they provide a better understanding of theoretical sampling. Therefore, after explaining the differences, other findings were discussed under the following titles: 1- Definitions and characteristics of theoretical sampling, including definitions and some of its characteristics. 2- Issues of theoretical sampling, including theoretical sampling of data archive; the differences between theoretical, purposeful and selective sampling; saturation and credibility in theoretical sampling. 6.1. Differences Between Qualitative and Quantitative Sampling The methodology of qualitative and quantitative research differs in their underlying assumption which leads to differences in sampling objectives and strategies, reliability and validity related issues, generalizability and repeatability (3, 20, 21). Quantitative research assumptions are concerned with distribution and statistical power. These assumptions are the cornerstones of sampling decision-making and support designing stronger causal inferences. The underlying assumptions are based upon statistical theories and central limit theorem in particular, which describes the distribution of variables among the population (20). It is assumed that the population parameters are normally distributed. But qualitative researchers are not looking for representativeness; they usually make no assumption regarding normal distribution of individuals’ experiences or interactions and settings (4). Nurs Midwifery Stud. 2017; 6(2):e38284. Sampling in quantitative research is a random selection of a part of the population. Researchers generalize results respecting the target population which is representative of the larger population. Therefore, how to choose the target population from the larger population is of prime importance as it should represent the main characteristics of a larger population. Researchers employing qualitative sampling place more emphasis on concepts and seek incidents related to them (22). Consequently, it can be asserted that qualitative research emphasizes the saturation and quantitative research emphasizes the generalization (23-25). Sampling techniques in quantitative research are used to reduce bias and enhance generalization, whereas qualitative researchers contend that their primary goal is creating a mirror or window-like prospect of a particular situation or phenomenon being investigated (26). Moreover, the nature of a proper sample differs in qualitative and quantitative research (27). Cases and not variables are examined in qualitative research. Qualitative researchers seek people, events or experiences with rich and specific information. Qualitative Articles Paper

Participants in qualitative research are selected not to represent the population distribution, but to provide a unique vision for the phenomenon (20, 28). Qualitative researchers, considering concepts, seek differences and not the similarities. They assert that variations would expand the broadness of concepts and scope of the theory (22). Qualitative researchers take negative and extreme cases into consideration for their unique insights, but quantitative researchers tend to exclude outliers by random sampling (3). In addition, in quantitative sampling, researcher measures sample size before the study. The sample size is considered as a constant goal throughout the study. Quantitative researchers can use others’ studies and find clues regarding the sample size and by analyzing them provide appropriate power to track down effects. Qualitative sampling is an iterative series of decisions in the research process. Therefore, samples in qualitative research are not necessarily constant, their nature is emergent. A thoughtful and reflexive researcher makes some revisions concerning his/her interpretation and explains the sampling consequences (8, 29). The information richness of each case in qualitative research explicates the reason for a smaller sample size in contrast with quantitative research (20). On the other hand it is believed that in qualitative research, since the phenomena are studied and interpreted in their natural setting, the context affects the meaning of events. Researchers tend to interpret and understand the phenomena with respect to the meanings presented by people (27). However, this is not the case in quantitative sampling. 3 Davoudi N et al. Potential relevant articles from electronic databases and screened for retrieval in • • • • • • • • • • • • • • • • • • • • • Pubmed keyword: theoretical sampling [Title]: N = 5 Pubmed keyword: qualitative sampling [Title]: N = 2 Pubmed MESH: “Sampling Studies/methods”[Mesh]: N = 25 Science Direct: theoretical sampling [Title]: N = 67 Science Direct: qualitative sampling [Title]: N = 83 Scopus : theoretical sampling [Title], article or review: N = 85 Scopu s: qualitative sampling [Title], article or review: N = 62 Ovid: theoretical sampling [Title]: N = 3 Ovid: qualitative sampling [Title]: N = 1 ProQuest: theoretical sampling [Title]: N = 19 ProQuest: qualitative sampling [Title]: N = 30 Wiley: theoretical sampling [Title]: N = 20 Wiley: qualitative sampling [Title]: N = 33 Google Scholar: theoretical sampling, with exact phrase, in the title of the article, exclude patents and citations: N = 30 Google Scholar: qualitative sampling, with exact phrase, in the title of the article, exclude patents and citations: Qualitative Articles Paper

N = 34 SID: theoretical sampling (in Persian) [Title]: N = 0 SID: qualitative sampling (in Persian) [Title]: N = 0 Magiran: theoretical sampling (in Persian) [Title]: N = 52 Magiran: qualitative sampling (in Persian) [Title]: N = 7 Iran Medex: theoretical sampling (in Persian) [Title]: N = 0 Iran Medex: qualitative sampling (in Persian) [Title]: N = 4 Total number= 562 E-Books were excluded N=4 Not English or Persian articles were excluded N=3 Irrelevant articles to the aims of the study were excluded N = 440 Duplicated articles were excluded N = 53 Articles without full text were excluded N = 32 Full-text articles included in the review N = 30 Books were included N=9 Articles and Books included in the final review N = 39 Figure 1. Flowchart of the Review Process 4 Nurs Midwifery Stud. 2017; 6(2):e38284. Davoudi N et al. 6.1.1. Definitions and Characteristics of Theoretical Sampling 6.1.1.1. Definition of Theoretical Sampling Despite improvements in grounded theory, the basic definition of theoretical sampling is almost unchanged. Glaser defined theoretical sampling as “the process of generating theory whereby the analyst jointly collects, codes and analyses his data and decides which data to collect next and where to find them to develop his theory as it emerges” (30). Despite different epistemological assumptions, Charmaz presented a similar description for theoretical sampling, highlighting data collection, increasing analytical abstraction of theory by clarifying variation and identifying gaps which need interpretation (31). Strauss and Corbin believed that theoretical sampling is meant to maximize opportunities of discovering variations in concepts and it is used to densify categories in terms of their properties and dimensions (32). According to Polit and Beck, a theory based sampling is the process of selecting incidents, slices of life, time periods, or people on the basis of their potential manifestation or representation of important theoretical constructs (33). 6.1.1.2. Some Characteristics of Theoretical Sampling Researchers mentioned some characteristics of theoretical sampling each of which is explained in full detail: – At the beginning of a study, theoretical sampling is open-ended and as the study progresses, it emerges (26). – Theoretical sampling is grounded in the concepts in which their theoretical relationship with the emerging theory is confirmed (34). In fact, it can be said that theoretical sampling is directed by concept. Concepts are sampled in the data and participants provide data which inform us of the concepts. Therefore, in theoretical sampling, researchers refer to locations, persons and situations which provide information respecting their selected concepts (22, 35, 36). – Qualitative Articles Paper

It is essential to employ theoretical sampling as a major feature of grounded theory in the inductive-deductive process. Inductive process includes the emergence of theory from data and deductive process includes purposeful selection of samples to test the emerging theory (37). – Given that guided interviews or selecting the best strategy for data collection is determined by the emergence of theoretical concepts, researcher relies on the ability of the initial participants to demonstrate the elements of the research topic (38). – Theoretical sampling is indeed a kind of triangulation and is used to confirm research findings. This method helps researchers to correct or add interview questions, change the observation method, select new informants and change the selection criteria to elucidate data obtained through analysis (39). Nurs Midwifery Stud. 2017; 6(2):e38284. – Theoretical sampling uses the constant comparative method (39). As the process of data analysis is applied, each event is compared with other events in terms of similarities or differences. This comparison allows researchers to distinguish between categories and themes and identify their dimensions plus properties (22). According to Patton as cited by Suri, researchers who apply constant comparative method can utilize theoretical sampling. Hence, theoretical sampling is used to systematically elucidate and refine the variations found in manifestations and meanings of the emergent concept (40). – Studying new and unexplored area reveals the importance of theoretical sampling. It allows researchers to explore, discover and benefit from accidental events (22). – As the time passes, theoretical sampling is planned and researchers check back their assumptions. Given that participants are selected in different situations and their presence is needed to clarify researcher’s understanding, then the research process should be explained in depth for budget agencies (41). 6.1.2. Issues of Theoretical Sampling 6.1.2.1. The Possibility of Theoretical Sampling From Data Archive Researchers can sample available collected data concerning the concept. Reviewing analyzed data, and regarding them with a new perspective is not exceptional. Since events related to a concept may have already been overlooked and their significance not valued. Documents such as newspapers and books may be used as data sources. Sampling is exactly the same as when data are collected through interviews, observations or field notes by coding and sampling. Documentary data may be found in several libraries, organizations, populations or regions. Consequently, the researchers should reason where the relevant events can be found and sampled. Some documents may consist of interviews or field notes that were collected by another researcher (22). 6.1.2.2. Qualitative Articles Paper

The Difference Between Theoretical and Purposeful Sampling There are different opinions concerning the differences between theoretical and purposeful sampling. Some researchers assert that all sampling methods in qualitative research are purposeful (42), or can be placed under a broad umbrella of purposeful sampling (43). Since they all tend to achieve a specific and defined objective (37, 42). In addition, theoretical sampling is considered as a form of or synonymous with purposeful sampling by some researchers (20, 44, 45). They contend that purposeful/theoretical sampling attempts to select participants respecting these items: determined criteria by research pur5 Davoudi N et al. pose, under the guidance of a theory, with the purpose of refining and elucidating the emerging theory (10, 46). Based on this feature, when a researcher applying a theoretical sampling notices an emerging process, he/she will purposefully seek new data. Hence a more appropriate term for theoretical sampling can be “analysis-driven purposeful sampling” or “analysis-governed purposeful sampling” (37). Moreover, other researchers pointed out the application of purposeful or selective sampling at the beginning of theoretical sampling and argued that it is inevitable to apply some degrees of judgment in the early stages of sample selection (47). For example, Thompson believes that data collected via selective sampling as “tentative theoretical jumping off points from which to begin theory development” (48). Therefore, phenomenal or demographic characteristics can be the starting points (49). According to Glaser, “initial sampling decisions are based on a general sociological perspective and a general problem, but once data are collected and coding begins, the researcher is led in all directions which seem relevant and work” (30). Therefore, in the process of employing theoretical sampling, the researcher can start with selective sampling and when the concepts emerge, he inclines toward theoretical sampling (11). However, some researchers state that theoretical sampling differs from other sampling strategies of purposeful or selective sampling, which are applied in qualitative research (50). Purposeful sampling involves identification and selection of individuals or groups who possess a particular knowledge or experience regarding a phenomenon. Qualitative Articles Paper

In addition to the knowledge and experience, Spradley as cited by Palinkas et al. believes that purposeful sample in a qualitative research should have the following features: noticing the importance of availability, willingness to participate in research, and the ability to share experiences and ideas in a detailed, expressive and reflexive way (23). Strauss and Corbin mentioned that purposeful sampling points to a strategy that researcher evaluates his judgment related to participants who provide the best perspective for the phenomenon and then purposefully invites those particular perspectives into the research (32). Moreover, to ensure selecting the richest information provided by participants, the researcher determines a set of inclusion and exclusion criteria. These criteria are grounded in research questions designed comparatively regarding prior knowledge of subject matter or initial study of related articles (10), but theoretical sampling is understood in context (37), since sampling criteria and its size in this method emerge as the study progresses (37, 51) and researchers applying theoretical sampling do not know exactly where and what sample they are directed to 6 (10). Glaser suggests that in theoretical sampling, the researcher should always be ready to change the interview approach, data collection sources, and participants as data patterns emerge (30). Hence, researcher waits for the sample selection to be formed by concurrent data collection and analysis (5), while a purposeful sample is selected by a predetermined aim at the beginning of the study (10). In this field, the exploration of various studies showed that grounded theorists, in some cases, applied purposeful sampling instead of theoretical sampling in their studies (52-54). In addition, in some studies, they started the study using purposeful sampling (and a mention of inclusion and exclusion criteria), but as the study headed forth and developed, theoretical sampling was employed (12, 13, 55). 6.1.2.3. Saturation in Theoretical Sampling Since qualitative studies do not aim at statistical generalizations, many of qualitative researchers state that sample size and sampling designs are not issues and challenges in qualitative research (27); though a novice researcher is concerned with where to start a research and where to stop data collection (10). The term “saturation” in qualitative research is an ambiguous concept and is frequently misinterpreted (10). Researchers have a few disagreements over its definitions and applications, which are as follows: Qualitative Articles Paper

Some researchers believe that in a qualitative research, stopping data collection relates to saturation or information redundancy. Redundancy is the continuous process of conducting and analyzing interviews which last until all concepts are repeated several times. When researcher concludes that the conceptual wellspring is dried up, interviewees repeat each other’s ideas and no new concept or theme emerges in the following interview, he stops being redundant. But saturation is achieved when all questions are explored thoroughly and in detail (6, 21). In this regard, some researchers assert that theoretical saturation (in grounded theory) and qualitative saturation differ essentially. A qualitative researcher pursues descriptive saturation, but a grounded theorist pursues saturation at a conceptual level (10). Roy contends that descriptive data saturation happens when researchers can predict things they have seen or heard frequently (5). But theoretical saturation in grounded theory is not purely descriptive redundancy. According to Glaser and Strauss as cited by Breckenridge and Jones, the purpose of theoretical sampling is not descriptive coverage. Dense categories provided by descriptive redundancy do not necessarily indicate an understanding needed by theoretical saturation (10). Theoretical saturation is an inductive process that indicates category development. This presents properties and dimenNurs Midwifery Stud. 2017; 6(2):e38284. Davoudi N et al. sions of categories, including variation and possible relationships with other concepts (22). Consequently, theorists saturate categories with more explanatory power and integrate them around a core variable. Therefore, the theorists are capable of acting beyond the typical descriptive level of a qualitative research and present the theoretical essence of a substantive area. In grounded theory, saturation is not related to confirming hypothesis and describing a specific situation at a specific time. In theoretical saturation, researcher is interested in creating a theory that can overcome changing situations. In grounded theory, theoretical sampling and the sampling end point are controlled by the emerging theory (10). When there is no valuable and/or new idea concerning the theory development, sampling can be stopped. Regarding the quality of the developed theory, researchers can recognize when saturation has taken place (42, 51). Despite these descriptions, some researchers believe that data saturation and redundancy are closely related to theoretical saturation; hence, the richness of data clarifies the theoretical development (5). In general, concerning sampling end point, researchers should be aware not to conclude soon. Sometimes when the researchers use the term saturated categories, they truly mean “they” are saturated with the process of data collection. In such circumstances, their time, money, and energy are finished and research is called off very soon and some gaps remain. Qualitative Articles Paper

Qualitative Articles Paper. It is unlikely that five or six interviews lead to saturation (22). Ryan and Bernard showed that saturation is connected with researcher’s experience and fatigue and the number of analysts who review the data. In other words, theoretical saturation relates to the researcher or research team’s skills (56). Therefore, for those who apply grounded theory for the first time, understanding the concept of theoretical saturation is probably difficult. Then, they never experience reaching the saturation point (10). A review of studies indicated that grounded theorists’ researchers have different conceptions and understandings of ‘saturation’; for example, Ashghali Farahani et al. considered their data as saturated when the new data could not provide any new theoretical insight or new characteristics for categories (57). Similarly, Heidari et al. also reported that they considered their data saturated when by increasing the number of samples, new data were not achieved (58). Other researchers believe that data saturation means that no new concept which needs creation of a new code is gained (53, 54). Seidi et al. wrote on saturation as the time when there are no new data emerging and clarification of interrelationships between concepts and sub categories with no emergence of new category, evolution of axial categories and gradual emergence of theory Nurs Midwifery Stud. 2017; 6(2):e38284. (55). Furthermore, Silva et al. pointed out that theoretical saturation happens when collecting new data makes no changes in the consistency and theoretical density of the emergent concepts (59). Vandecasteele et al. believed that saturation means when you cannot glean any new information and the interrelations between concepts are observed clearly (12). As it can be observed in the review of such studies, the researchers frequently use the concept of “data saturation” interchangeably with “theoretical saturation”. 6.1.2.4. Evaluating the Credibility of Theoretical Sampling In the past decades, despite the growing popularity of qualitative research, it is criticized for its ambiguous process and procedures. Many published qualitative researches provide little information regarding features of studied sample, sample or process type and sampling techniques (8). One of the major problems of applying theoretical sampling is using this method without adequate understanding of grounded theory which leads to inability to clarify sampling strategy. Inappropriate application of grounded theory is harshly criticized, since it seems that with a sleight of hand, researchers create a set of themes. Qualitative Articles Paper

Thus, with no step by step explanation of how to achieve this theoretical insight, people are invited to believe their theory (10). Sampling is essentially needed to determine research quality. Providing an exact description of participants is one of the credibility elements in qualitative research (6, 10). It is recommended that novice grounded theorists avoid a separate, on-off, and static description and instead concentrate on the theoretical sampling development, justification and decision making. Their explication should reflect the complex process of theory development (10). Researchers should explicate, in detail, the decision making process for sampling and systematic procedures to achieve research samples. If research findings cannot explicitly connect to the research process, it is difficult to determine research credibility (8, 24, 25). On the other hand, qualitative researchers believe that the adequacy of theoretical sampling should be judged regarding the process of theory production. Glaser and Strauss as cited by Breckenridge and Jones, acknowledge that an inadequate theoretical sampling leads to creating a theory that has lots of gaps and lacks integration and comprehensiveness. Given that the credibility of a theory or any part of a research cannot be separated from its production process, the researcher should present evidence that the final theoretical products are really grounded. The researcher should pay attention to theoretical sampling process and indicate how theoretical insights turn into an abstract theory. Therefore, he can reveal the complexity of theory development (10). 7 Davoudi N et al. Corbin and Strauss pointed out that the evaluation and judgment criteria respecting the quality of grounded theory involve the evaluation criteria of theoretical sampling. They suggested that in research evaluation, the following factors should be taken into account: – How were the original sample and its following sample selected? – Which categories was theoretical sampling based on? – How did theoretical formulation direct data collection? – How did descriptions related to theoretical sampling determine that categories were obtained from the data? (22). A review of literatures using grounded theory indicated that in some of the studies, researchers sufficed only to defining theoretical sampling and did not mention any practical realities of theoretical sampling process in their studies. For example, in the studies by Ward et al. and Shirazi et al. the process of researchers’ access to theoretical insights was unclear for the readers (13, 60). 7. Conclusions Theoretical sampling is the process of data collection for theory generation. The review of literature indicated that despite disagreements and challenges regarding some operational application of theoretical sampling, there were agreements and general consensus respecting the significance of theoretical sampling and its influence over quality of theory. Therefore, it is recommended that researchers explicate the decision making process in detail, since they apply theoretical sampling in their studies. Researchers should also justify the selection and the sequence of sampling process to explain the complicated process of analytical abstraction and theory development by empirical data. Consequently, the credibility of their theory and research is enhanced. Qualitative Articles Paper

Footnotes Authors’ Contribution: Study concept and design (Nayyereh Davoudi, Nahid Dehghan Nayeri); searching databases and selecting the articles: (Nayyereh Davoudi, Afsaneh Raiesifar, Sarieh Poortaghi, Shamsi Ahmadian); interpretation of data: (Nayyereh Davoudi, Nahid Dehghan Nayeri); drafting the manuscript: (Nayyereh Davoudi); critical revision of the manuscript: (Nahid Dehghan Nayeri, Afsaneh Raiesifar, Sarieh Poortaghi, Shamsi Ahmadian); all authors read, revised and approved the final copy of the manuscript. 8 Financial Disclosure: The authors declared no conflict of interest regarding the materials and results of the current study. Funding/Support: There was no financial support for the current study. References 1. Omona J. Sampling in qualitative research: Improving the quality of research outcomes in higher education. Makerere J High Educ. 2013;4(2) doi: 10.4314/majohe.v4i2.4. 2. Kearney MH. Going deeper versus wider in qualitative sampling. J Obstet Gynecol Neonatal Nurs. 2007;36(4):299. doi: 10.1111/j.15526909.2007.00167.x. [PubMed: 17594402]. 3. Abrams LS. Sampling ’hard to reach’ populations in qualitative research: The case of incarcerated youth. Qual Soc Work. 2010;9(4):536– 50. doi: 10.1177/1473325010367821. 4. Marshall MN. Sampling for qualitative research. Fam Pract. 1996;13(6):522–5. [PubMed: 9023528]. 5. Roy K, Zvonkovic A, Goldberg A, Sharp E, LaRossa R. Sampling richness and qualitative integrity: Challenges for research with families. J Marriage Family. 2015;77(1):243–60. doi: 10.1111/jomf.12147. 6. Gibbs L, Kealy M, Willis K, Green J, Welch N, Daly J. What have sampling and data collection got to do with good qualitative research?. Aust N Z J Public Health. 2007;31(6):540–4. doi: 10.1111/j.1753-6405.2007.00140.x. [PubMed: 18081574]. 7. Patton MQ. Qualitative evaluation and research methods. Newbury Park: SAGE Publications, Inc; 1990. 8. Higginbottom GM. Sampling issues in qualitative research. Nurse Res. 2004;12(1):7–19. doi: 10.7748/nr2004.07.12.1.7.c5927. [PubMed: 15493211]. 9. Harris T. Grounded theory. Nurs Stand. 2015;29(35):32–9. doi: 10.7748/ns.29.35.32.e9568. [PubMed: 25922026]. 10. Breckenridge J, Jones D. Demystifying theoretical sampling in grounded theory research. Ground Theor Rev. 2009;8(2):113–26. 11. Draucker CB, Martsolf DS, Ross R, Rusk TB. Theoretical sampling and category development in grounded theory. Qual Health Res. 2007;17(8):1137–48. doi: 10.1177/1049732307308450. [PubMed: 17928484]. 12. Vandecasteele T, Debyser B, Van Hecke A, De Backer T, Beeckman D, Verhaeghe S. Nurses’ perceptions of transgressive behaviour in care relationships: a qualitative study. J Adv Nurs. 2015;71(12):2786–98. doi: 10.1111/jan.12749. [PubMed: 26250148]. 13. Ward K, Gott M, Hoare K. Participants’ views of telephone interviews within a grounded theory study. Qualitative Articles Paper

J Adv Nurs. 2015;71(12):2775–85. doi: 10.1111/jan.12748. [PubMed: 26256835]. 14. Moudi Z, Abed Saeedi Z, Ghazi Tabatabaie M. How baloch women make decisions about the risks associated with different childbirth settings in southeast iran. Nurs Midwifery Stud. 2015;4(1):e24453. [PubMed: 25830159]. 15. Mirzaee Rabor F, Taghipour A, Mirzaee M, Mirzaii Najmabadi K, Fazilat Pour M, Fattahi Masoum SH. Developing a Questionnaire for Iranian Women’s Attitude on Medical Ethics in Vaginal Childbirth. Nurs Midwifery Stud. 2015;4(4):e29004. doi: 10.17795/nmsjournal29004. [PubMed: 26835464]. 16. Masoudi Alavi N, Ghofranipour F, Ahmadi F, Babaee G, Rajab A, Emami A. Explanatory model of diabetes management; an experience from Iran. Nurs Midwifery Study. 2012;1(2):100–6. 17. Seylani K, Karlsson S, Hallberg IR, Mohammadi E, Negarandeh R. Spirituality among iranian nursing students during undergraduate study. Nurs Midwifery Study. 2016;5(3):e33044. . Nurs Midwifery Stud. 2017; 6(2):e38284. Davoudi N et al. 18. Yarmohammadian MH, Mohammadi E, Movahedi F. Standards for writing review articles [in Persian]. Health Inf Manag. 2012;8(8):1226– 34. 19. Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91–108. doi: 10.1111/j.1471-1842.2009.00848.x. [PubMed: 19490148]. 20. Ayres L. Qualitative research proposals–part III: sampling and data collection. J Wound Ostomy Continence Nurs. 2007;34(3):242–4. doi: 10.1097/01.WON.0000270816.99318.3b. [PubMed: 17505241]. 21. Trotter RT. Qualitative research sample design and sample size: resolving and unresolved issues and inferential imperatives. Prev Med. 2012;55(5):398–400. doi: 10.1016/j.ypmed.2012.07.003. [PubMed: 22800684]. 22. Corbin J, Strauss A. Basics of qualitative research: Techniques and procedures for developing grounded theory. 3 ed. Thousand Oaks: SAGE Publications, Inc; 2008. 23. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health. 2015;42(5):533–44. doi: 10.1007/s10488-013-0528-y. [PubMed: 24193818]. 24. Byrne M. Sampling for qualitative research. AORN J. 2001;73(2):494–8. [PubMed: 11218935]. 25. Luborsky MR, Rubinstein RL. Sampling in Qualitative Research: Rationale, Issues, and Methods. Res Aging. 1995;17(1):89–113. doi: 10.1177/0164027595171005. [PubMed: 22058580]. 26. Koerber A, McMichael L. Qualitative sampling methods a primer for technical communicators. J Bus Tech Comm. 2008;22(4):454–73. 27. Onwuegbuzie AJ, Leech NL. Sampling designs in qualitative research: Making the sampling process more public. Qual Rep. 2007;12(2):238– 54. 28. Jalali R. qualitative research sampling. J Qual Res Health Sci. 2013;1(4):310–20. 29. Qualitative Articles Paper

Guetterman TC. Descriptions of sampling practices within five approaches to qualitative research in education and the health sciences. Forum Qual Soc Res. 2015;16(2):Art. 25. 30. Glaser BG. Advances in the methodology of grounded theory: Theoretical sensitivity. Mill Valley, CA: Sociology Press; 1978. 31. Charmaz K. Constructing grounded theory: A practical guide through qualitative analysis. London: SAGE Publications; 2006. 32. Strauss A, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory. SAGE Publications, Inc; 1998. 33. Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice. 9 ed. Philadelphia: Lippincott Williams & Wilkins; 2012. 34. Seale C, Gobo G, Gubrium J, Silverman D. Qualitative research practice. London: SAGE Publications; 2004. 35. Boswell C, Cannon S. Introduction to nursing research, incorporating evidence based practice. Boston: Jones & Bartlett Publishers; 2007. 36. Ranjbar H, Haghdoost AA, Salsali M, Khoshdel A, Soleimani M, Bahrami N. Sampling in qualitative research: A Guide for beginning [in Persian]. Ann Mil Health Sci Res. 2012;10(3):238–50. 37. Coyne IT. Sampling in qualitative research. Purposeful and theoretical sampling; merging or clear boundaries?. J Adv Nurs. 1997;26(3):623–30. [PubMed: 9378886]. 38. Currie K. Using survey data to assist theoretical sampling in grounded theory research. Nurse Res. 2009;17(1):24–33. doi: 10.7748/nr2009.10.17.1.24.c7336. [PubMed: 19911651]. 39. Houser J. Nursing research: Reading, using and creating evidence. Jones & Bartlett Publishers; 2008. 40. Suri H. Purposeful sampling in qualitative research synthesis. Qual Nurs Midwifery Stud. 2017; 6(2):e38284. Res J. 2011;11(2):63–75. doi: http://dx.doi.org/10.3316/QRJ1102063. 41. Bagnasco A, Ghirotto L, Sasso L. Theoretical sampling. J Adv Nurs. 2014;70(11):e6–7. doi: 10.1111/jan.12450. [PubMed: 24889554]. 42. Holloway I, Wheeler S. Qualitative research in nursing and healthcare. John Wiley & Sons; 2010. 43. Sandelowski M. Sample size in qualitative research. Res Nurs Health. 1995;18(2):179–83. [PubMed: 7899572]. 44. Wilmot A. Designing sampling strategies for qualitative social research: With particular reference to the office for national statistics’ qualitative respondent register. Surv Meth Bull Off Natl Stat. 2005;56:53. 45. Bowers D, House A, Owens D. Getting started in health research. John Wiley & Sons; 2011. 46. Tuckett AG. Qualitative research sampling: the very real complexities. Qualitative Articles Paper

Nurse Res. 2004;12(1):47–61. doi: 10.7748/nr2004.07.12.1.47.c5930. [PubMed: 15493214]. 47. Curtis S, Gesler W, Smith G, Washburn S. Approaches to sampling and case selection in qualitative research: examples in the geography of health. Soc Sci Med. 2000;50(7-8):1001–14. [PubMed: 10714922]. 48. Thompson C. Qualitative research into nurse decision making: factors for consideration in theoretical sampling. Qual Health Res. 1999;9(6):815–28. [PubMed: 10662261]. 49. Waltz CF, Strickland OL, Lenz ER. Measurement in nursing and health research. Springer Publishing Company; 2010. 50. Robinson OC. Sampling in interview-based qualitative research: A theoretical and practical guide. Qual Res Psychol. 2014;11(1):25–41. doi: http://dx.doi.org/10.1080/14780887.2013.801543. 51. Streubert HJ, Carpenter DR. Qualitative research in nursing: Advancing the humanistic imperative. 5 ed. Philadelphia: Lippincott Williams & Wilkins; 2011. 52. Angerud KH, Brulin C, Eliasson M, Naslund U, Hornsten A. The Process of Care-seeking for Myocardial Infarction Among Patients With Diabetes. J Cardiovasc Nurs. 2015;30(5):E1–8. doi: 10.1097/JCN.0000000000000195. [PubMed: 25325370]. 53. Rosenthal MM, Molzahn AE, Chan CT, Cockfield SL, Kim SJ, Pauly RP. Why take the chance? A qualitative grounded theory study of nocturnal haemodialysis recipients who decline kidney transplantation. BMJ Open. 2016;6(5):e011951. doi: 10.1136/bmjopen-2016-011951. [PubMed: 27194322]. 54. van Gilst MM, Cramer IC, Bloem BR, Overeem S, Faber MJ. A grounded theory study on the influence of sleep on Parkinson’s symptoms. BMC Res Notes. 2016;9:299. doi: 10.1186/s13104-016-2114-3. [PubMed: 27283443]. 55. Seidi J, Alhani F, Salsali M. Exploration of structure of clinical judgment of nurses: A grounded theory study [in Persian]. J Qual Res Health Sci. 2014;2(4):297–309. 56. Ryan GW, Bernard HR. Techniques to identify themes. Field Method. 2003;15(1):85–109. 57. Ashghali-Farahani M, Mohammadi E, Ahmadi F, Maleki M, Hajizadeh E. Obstacles of patient education in CCU and post CCU: A grounded theory study [in Persian]. Iran J Nurs. 2009;22(58):55–73. 58. Heidari MR, Anooshe M, Azadarmaki T, Mohammadi E. The process of patient’s privacy: A grounded theory. J Shahid Sadoughi Univ Med Sci. 2012;19(5):644–54. 59. da Silva TP, da Silva MM, Valadares GV, Silva IR, Leite JL. Nursing care management for children hospitalized with chronic conditions. Rev Bras Enferm. 2015;68(4):556–63. doi: 10.1590/0034-7167.2015680410i. [PubMed: 26422035] 641-8. 60. Shirazi M, Manoochehri H, Zagheri TM, Zayeri F, Alipour V. Explaining of chronic pain management process in older people: A grounded theory Study [in Persian]. Med Surg Nurs J. 2016;4(4):1–11. 9 Copyright of Nursing & Midwifery Studies is the property of Medknow Qualitative Articles Paper

Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Writing & Research Qualitative Research: An Introduction Jennifer Yates, EdD, R.T.(R)(M)(BD) Tricia Leggett, DHEd, R.T.(R)(QM) W hat is qualitative research? How does it differ from quantitative research? Under what circumstances is one type of study more appropriate than the other? Are there instances where one might consider a “mixed methods” approach using elements of both? A researcher beginning a project faces a bewildering array of decisions regarding the approach he or she will take to answer the questions associated with the problem being investigated. An analysis of peer-reviewed articles published in Radiologic Technology from September/ October 2010 to July/August 2016 yielded 90 total articles. Quantitative survey studies or other quantitative research (eg, correlative studies) represented the largest percentage of articles, 36.6%. Experimental studies represented 24.4% of articles; 20% were literature reviews, and 13.3% were case or technical reports. Mixedmethods studies (using both qualitative and quantitative methods of data collection) represented 3.3%, while purely qualitative studies represented only 2.2% of published articles. Quantitative vs Qualitative Research Quantitative studies are appropriate for examining relationships between and among variables, describing trends, attitudes, or opinions of a population, as well as for testing the effects of a treatment or intervention on an outcome.1 Although quantitative analysis allows for a high degree of precision in research, it represents a 2-D RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 view of findings as compared to the rich, deep descriptions offered by qualitative approaches. The role of the researcher in a quantitative study is to remain “distant and independent of what is being researched” (ie, as objective as possible).2 Conversely, in qualitative research, the researcher is aware of the socially constructed nature of reality and is embedded intimately in the context of the study— the research setting, participants, and the data being collected. The qualitative researcher is a reflexive practitioner, aware of his or her own political and cultural perspectives, yet willing to engage in self-questioning and self-understanding. 3 Qualitative research gets at the how and why of the story, in ways that quantitative research cannot. The key concept of the study is often referred to as central phenomenon in scholarly writings. Other important differences include sample size, methods of data collection, analysis, and interpretation. Qualitative Articles Paper

Researchers within the radiologic science profession might consider using qualitative approaches alone or in combination with quantitative methods when planning future studies. Many comprehensive resources provide detailed information on designing qualitative research studies, and some are referenced in this column. Developing the Qualitative Research Question Developing the research question is the initial step in any research project. This frames the outline 225 Writing & Research Qualitative Research: An Introduction and process for the work to follow. Once the area for investigation is determined, the research problem will be posed. The research problem is a topic or issue that specifies the value of the research study. In general, completion of sentences such as, “This study needs to be conducted because…” or “The topic for this research is…,” indicate the beginnings of the qualitative research study. Next, narrowing the broad topic is the basis for the purpose statement (a statement that provides the premise for the research project). The purpose statement typically is a single sentence that describes the specificity of the research study (eg, the central phenomenon, the participants, and where the researchers are located).1 The framework of the purpose statement might look similar to this example: The purpose of this qualitative study is to understand the primary motivating factor for graduating radiologic science students in ambulatory care clinical settings. Once the purpose statement is created, the researcher must develop qualitative research questions. For qualitative research, a central question often is followed by 3 to 5 subquestions to further refine various aspects of the central question. The central question typically is open-ended to avoid being too focused or making assumptions before data collection. The more specific subquestions are categorized as to either issue or procedure and follow the same guidelines as with the central question. Issue subquestions narrow the focus of the central question and typically are placed immediately after the central question; the procedures’ subquestions might evolve after the research has begun because they address the process of the study and data analysis. It is important to note that subquestions assist in the formulation of surveys, structured interviews, or focus groups needed to collect pertinent data. The Box illustrates some common guidelines in developing qualitative research questions.1 Qualitative Data Collection Qualitative data collection often is open-ended to produce emerging themes during analysis. Common 226 Box Central and Subquestion Guidelines for Qualitative Research1  Begin with words such as how or what. Qualitative Articles Paper

 Tell the reader what you are attempting to discover, generate, explore, identify, or describe.  Ask “what happened?” to help craft your description.  Ask “what was the meaning to the participants?” to better understand the results.  Ask “what happened over time?” to explore the process.  Avoid words such as relate, influence, impact, effect, and cause; these words typically are associated with quantitative research studies. methods include interviews, focus groups, observations, reviewing document studies, key informants, alternative (authentic) assessments, and case studies. An interview, rather than a paper-and-pencil or electronic survey, is selected when interpersonal contact is important and when opportunities for follow-up of interesting comments are desired. Interview data can be recorded digitally (with participant permission), summarized in notes, or a combination of these methods. Detailed recording is a necessary component of interviews because it forms the basis for analysis. 4 A focus group can be considered an in-depth group interview. Typically, a group of about 10 participants is invited to a session that lasts approximately 2 hours. The researcher initiates discussion by asking openended questions so that the participants are motivated but not guided to discuss the relevant topic. The researcher listens and observes the discussions that follow, intervening as little as possible as long as the discussion remains on the topic. In such discussion, the participants are expected to unfold their knowledge and express their opinions about the subject matter. Observations are guided by a structured protocol that can take a variety of forms, ranging from the request for a narrative describing events to a checklist or a rating scale of specific behaviors or activities. This level of standardization helps assure consistency with RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 Writing & Research Yates, Leggett the data collection. Field notes frequently are used to provide more in-depth background or to help the observer remember events, if a form is not completed at the time of observation. Field notes contain the description of what was observed and must be factual, accurate, and without bias.4 Incorporating social media into qualitative research is emerging as evidenced by the development of an innovative data collection meta-framework by Onwuegbuzie et al.5 Qualitative Data Analysis and Interpretation Qualitative researchers must work directly and intimately with their data. This usually begins with reading interview transcripts or other textual material multiple times to identify emerging themes and categories. Researchers might analyze data inductively or deductively, depending on whether the study is exploratory or confirmatory. Many qualitative studies include elements of both. “Inductive analysis involves discovering patterns, themes, and categories in one’s data.”Qualitative Articles Paper

3 Deductive analysis begins with an existing framework. Often, researchers begin data analysis inductively, as a means for developing the conceptual framework and resulting codebook. The researcher then can move forward in a deductive manner, using the codes to identify and categorize pertinent quotes within the transcripts. Interpretation is the researcher’s process of making meaning of patterns, themes, and categories. In so doing, he or she determines ways in which the results answer the research questions and sometimes the results raise new questions. Some researchers code and extract pertinent passages from the transcript manually, some use the comment feature in Microsoft Word, and some use more sophisticated software programs designed to assist with qualitative analysis, such as Atlas.ti, NVivo, and NUDIST. Validity of Qualitative Research The validity of qualitative research refers to the extent to which findings accurately depict the phenomenon it is designed to investigate. 6 Qualitative research RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 studies can be validated by 1 of 3 generally accepted methods, or ideally by triangulation, which uses at least 2 of the methods. The first method to ensure valid data is the use of contradictory evidence, or deviant cases. This mode investigates any data that could be incorrect or the analysis might be misrepresented because of potential researcher bias. This is especially important because the data collection process needs to be as objective as possible. The next method is respondent validity, which provides the participants the opportunity to review the data and subsequent analysis for accuracy. Any inaccuracies can be corrected before further progress in the research study. Constant comparison is the final method, and it affords the ability to compare individual data sets to a larger set of data for consistency and continuity. This truly promotes a holistic analysis of the data.7 Designing a Qualitative Research Study Case Study Research Case reports appearing in Radiologic Technology often involve the in-depth presentation of a particular imaging challenge or patient pathology. Case study research as a qualitative approach uses a particular design and methods of data collection. Typically, “case studies are the preferred strategy when ‘how’ or ‘why’ questions are being posed, when the investigator has little control over events, and when the focus is on a contemporary phenomenon within some real-life context.”8 Case study research can be used to explore, describe, or explain. 8 The case might involve an individual, multiple individuals, groups, organizations, or a particular event.9 A multiple case study, as the name implies, uses sets of cases. The research setting is essential in providing context for the study. Often, multiple methods of data collection are used to triangulate findings. Sometimes quantitative methods of data collection and analysis are used as well. Qualitative Articles Paper

An example of a multiple case study research published in Radiologic Technology is Mazal and Ludwig’s study, “Using Mobile Electronic Devices to Deliver Educational Resources in Developing Countries.”10 Four users of electronic radiography texts represented the set of cases. Email-based, open-ended dialogue 227 Writing & Research Qualitative Research: An Introduction with each recipient represented the qualitative data collected, analyzed, and interpreted for this study. Participatory Action Research Qualitative methods, in addition to their use in research studies, can be used for evaluation purposes. Yates used the participatory action research approach as a means of program assessment and policy development.11 As the name implies, participation by all stakeholders is key to this type of research. Rather than imposing research on “subjects,” people being studied also participate in the research or evaluation to varying degrees. Often a strong social justice focus on the research study or evaluation process exists. Participatory action research12:  Is about the improvement of practice and creation of knowledge in social groups.  Can start anywhere and proceeds through complete cycles of planning, acting, reflecting, and observing.  Involves participation in all stages of those affected by changes in social practice and discourse.  Is participatory, often conducted by an action group with at least one expert. Action research is based in social inquiry and often is used to solve a pressing problem. Participatory action research involves collaboration and critical reflection of the researcher’s own practices. An important feature of participatory action research is the preservation of the voices and practices of people being studied. Data frequently is collected in the form of interviews, focus groups, and written text (eg, open-ended survey questions). When used effectively, participatory action research is a continuous cycle of “planning, acting, observing, and reflecting”13 that results in continuous improvement. The research has the potential to work well in educational settings, particularly in programs accredited by the Joint Review Committee on Education in Radiologic Technology, where the goal is continuous program improvement. Participatory action research can be effective in solving problems in imaging departments, where patient, staff, and physician input could improve delivery of service for continuous quality improvement. An example 228 of a participatory action research article published in Radiologic Technology is the Lopez et al study, “Florida Mammographer Disability Training vs Needs.”14 That study was designed to address the problem of lack of access to screening mammography for women with disabilities. Demographic and qualitative interview data were collected from 3 participant groups: mammographers, other health care providers (eg, physicians and nurses), and women with disabilities. Qualitative Articles Paper

The researchers concluded that mammographers were receiving disability training primarily on the job, and that they would benefit from training in “both technical and social aspects of performing mammography on women with disabilities, including positioning, disability etiquette, and disability advocacy.” Narrative Research Narrative research is best described as the study of lives through storytelling.15 Narrative research can be a singular approach or a research method of data collection used with other qualitative approaches. It can be biographical or autobiographical and “is best for capturing the detailed stories or life experiences of a single life or the lives of a small number of individuals.”16 In biographical narrative research, the researcher spends considerable time with the participant, often meeting on multiple occasions to gain an in-depth understanding of the person’s stories. In so doing, the researcher and participant develop a collaborative relationship. In general, most participants do not tell their stories in a strictly chronological order and it is the researcher’s task to order the stories and other data into a coherent whole. Aside from oral narratives, materials such as other people’s stories about the person being studied, letters, emails, diaries, and school records can be collected, analyzed, and interpreted. Narrative research is based on the premise that knowledge is socially constructed and situated within the context of the participants’ “personal experiences (their jobs, their home), their culture (racial or ethnic) and their historical contexts (time and place).”16 The researcher studies himself or herself in autobiography, and life history is the study of a person’s entire life. Narrative research can be focused upon individuals RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 Writing & Research Yates, Leggett who have shared similar experiences or centered on a particular research context, such as a hospital or school.16 Charon’s “Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust” is an example of the narrative method used in the context of medicine published in the Journal of the American Medical Association.17 In the article, she stated, “The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others.” She described narrative knowledge as a process by which physicians can share in a discourse with patients to understand their stories and suffering: “Along with scientific ability, physicians need the ability to listen to the narratives of the patient, grasp and honor their meanings, and be moved to act on the patient’s behalf.” Through this physician–patient discourse and through the physician’s engagement in self-reflection, care for sick patients can be delivered in a more sympathetic and humane manner. Qualitative Articles Paper

Grounded Theory Research The purpose of grounded theory research is to generate, rather than test, a theory.3 Grounded theory research is characterized by an iterative process used by the researcher. The researcher goes out to the field (ie, the natural setting in which the participants live and work) to collect data from individuals who share some common experience, or phenomenon. Data collection methods can include quantitative and qualitative data; but qualitative methods are used more commonly.16 The researcher goes back and forth from interviews to analysis, returning to the field to collect more data, until the themes and categories generated are saturated and no new information can be added. According to Creswell, “This process of taking information from data collection and comparing it to emerging categories is called the constant comparative method of data analysis.”16 The themes and categories centered on the shared experience of the participants (the phenomenon) are then used to identify causal conditions, strategies, intervening conditions, and consequences. In this manner, a hypothesis or theory emerges. Therefore, the theory is “‘grounded’ in data from the field.”16 An example RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 of grounded theory research in medicine appeared in Social Science and Medicine. In it, Charmaz provides a step-by-step guide to conducting grounded theory research by applying it to a discovery of a theory of chronic illness.18 Phenomenological Research Phenomenological research is “the study of the lived experiences of persons.”16 Phenomenological studies focus on a shared human experience, such as surviving breast cancer, experiencing the death of a child, or winning the lottery. The researcher collects data from participants (usually a small number) who have experienced the phenomenon, and through the process of analysis and interpretation, generates a description of the participants’ “meaning, structure, and essence of the lived experience.”3 Qualitative data can be collected in the form of in-depth interviews (often multiple interviews with the each participant), openended survey questions, diaries, journals, art forms, and other media in which the participant describes or depicts his or her experience. Phenomenological studies frequently are used in the context of medicine and the descriptions they provide might inform the development of policies and practices. An example of a phenomenological research study performed in the context of emergency medicine was published in the Journal of Emergency Nursing. Granero-Molina et al focused on the lived experience of medical professionals providing end-of-life care to patients in the emergency department.19 The authors examined factors that undermined the dignity of these patients including “architectural and organizational characteristics, professional’s attitudes, and decisions made by family members.” Qualitative Articles Paper

Ethnographic Research Ethnographic research is the study of an entire cultural group. An ethnographer “describes and interprets the shared and learned patterns of values, behaviors, beliefs, and language of a culture sharing group.”16 The researcher gathers information in the field. Qualitative data frequently consists of direct observation and in-depth interviews, although materials such as art 229 Writing & Research Qualitative Research: An Introduction forms and cultural artifacts might be useful as well. A fascinating and heartbreaking example of an ethnographic study relating to medicine is captured in Anne Fadiman’s book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures.20 The book describes a Laotian refugee family’s experiences in the American medical system through the course of long-term treatment of a child with severe epilepsy. The clash of cultures creates profound challenges in caring for the child, with devastating consequences. Conclusion The intent of this column is to provide an introduction to qualitative research and to present an overview of a limited number of possible approaches. Increasing the number of qualitative and mixed-methods studies published in Radiologic Technology will enrich the body of knowledge within the radiologic science profession. Jennifer Yates, EdD, R.T.(R)(M)(BD), is program director for Merritt College in Oakland, California. She is a member of the Radiologic Technology Editorial Review Board and can be reached at jyates@peralta.edu. Tricia Leggett, DHEd, R.T.(R)(QM), is vice president for student success for Zane State College in Zanesville, Ohio. She is vice chairman of the Radiologic Technology Editorial Review Board and can be reached at tleggett@ zanestate.edu. References 1. Creswell JW. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 2nd ed. Thousand Oaks, CA: Sage; 2003. 2. Abawi K. Qualitative and quantitative research. Talk presented at: Ministry of Public Health Reproductive Health Research Methodology Training; January 3-12, 2008; Kabul, Afghanistan. http://www.gfmer.ch/Medical_education_En /Afghanistan_2008/pdf/Qualitative_quantitative _research_Abawi_Afghanistan_2008.pdf. Accessed September 23, 2016. 3. Patton MQ. Qualitative Research & Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage Publishing; 2002. 230 4. Overview of qualitative methods and analytic techniques: common qualitative methods. National Science Foundation Web site. https://www.nsf.gov/pubs/1997/nsf97153/chap_3 .htm. Published 1997. Accessed September 13, 2016. 5. Onwuegbuzie A, Leech N, Collins K. Innovative data collection strategies in qualitative research. Qual Rep. 2010;15(3):696-726. 6. Fraenkel J, Wallen N. How to Design and Evaluate Research in Higher Education. 6th ed. Qualitative Articles Paper

New York City, NY: McGraw Hill Companies Inc; 2003. 7. Anderson C. Presenting and evaluating qualitative research. Am J Pharm Educ. 2010;74(8):141. 8. Yin RK. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: Sage Publishing; 2003. 9. Robson C. Real World Research. 2nd ed. Malden, MA: Blackwell; 2002. 10. Mazal JR, Ludwig R. Using mobile electronic devices to deliver educational resources in developing countries. Radiol Technol. 2015;86(5):490-498. 11. Yates JL. Participatory action research for program planning. Radiol Sci Educ. 2006;11(1):7-18. 12. Hughes I. Action research electronic reader: introduction. Action Research & Action Learning Web site. http://www .aral.com.au/arow/rintro.html. Published 1997. Accessed September 7, 2016. 13. Action research. University of Warwick Learning and Development Centre Web site. https://www2.warwick.ac.uk /services/ldc/resource/evaluation/tools/action/. Revised July 10, 2012. Accessed September 7, 2016. 14. Lopez ED, Vasudevan V, Lanzone M, et al. Florida mammographer disability training vs needs. Radiol Technol. 2012;83(4):337-348. 15. Sandelowski M. Telling stories: narrative approaches to qualitative research. Image J Nurs Sch. 1991;23(3):161-166. http:// academic.son.wisc.edu/courses/N701/week/sandelowski _tellingstories.pdf Accessed September 7, 2016. 16. Creswell JW. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. 2nd ed. Thousand Oaks, CA: Sage Publishing; 2007. 17. Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902. 18. Charmaz K. ‘Discovering’ chronic illness: using grounded theory. Soc Sci Med. 1990;30(11):1161-1172. 19. Granero-Molina J, Díaz-Cortés MM, Hernández-Padilla JM, Garcia-Caro MP, Fernández-Sola C. Loss of dignity in end-of-life care in the emergency department: a phenom- RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 Writing & Research Yates, Leggett enological study with health professionals. J Emerg Nurs. 2016;42(3):233-239. doi:10.1016/j.jen.2015.10.020. 20. Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York City, NY: Farrar, Strauss, and Giroux; 1997. You have an idea, a question, a trick to share. We have an audience, a simple process and people to help. Start with an idea. Complete a review. Review your resources. Make a decision. Write your article. Work out details with the author. Submit it. Publish the article.* *Although many articles are published — most after revisions are requested — some are outside the scope of the journal and, therefore, not published by ASRT. www.asrt.org/authorguide RADIOLOGIC TECHNOLOGY, November/December 2016, Volume 88, Number 2 231 Copyright of Radiologic Technology is the property of American Society of Radiologic Technologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. Qualitative Articles Paper

However, users may print, download, or email articles for individual use. Nursing Practice Today Nurs Pract Today. 2017; 4(2):64-66. Editorial Quality in the qualitative content analysis studies Asra Nassehi1,2, Maryam Esmaeili1,3*, Shokoh Varaei4 1 Critical Care Department, School Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran Faculty of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran 3 Nursing and Midwifery Care Research Center, Tehran University of Medical Sciences, Tehran, Iran 4 Medical Surgical Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran 2 In the healthcare system, the aim of qualitative studies is to deeply evaluate the complex phenomena that nurses and other health staff might encounter. One of the main characteristics of qualitative studies is determination and in-depth recognition of the studied phenomenon, participants’ experiences and enriched narration of the achieved results (1). On the other hand, due to lack of scientific accuracy, lack of transparency in the analysis methods, results’ dependence on researchers’ personal point of view and also non-generalizability, qualitative studies have always been criticized. Therefore, due to an extended use of qualitative research in the field of nursing, one of the duties of nursing researchers is to improve the quality of qualitative studies (2). A qualitative study is not a singular research approach; instead, different approaches of epistemology have created a wide range in the approaches of qualitative studies, such as grounded theory, phenomenology, ethnography, action research and content analysis (3). Burns and Grove believed that content analysis is one of the qualitative research methods which would be conducted for categorizing the words of a text; these categories would be established because of the importance of the words in a formation of theories (4). Also, Polit and Beck stated that content analysis is the process of organizing and integrating the texts and qualitative data in a way that it would lead to the formation of themes and concepts (5). Besides this methodological view at content analysis and categorizing it as a qualitative research method, another viewpoint considers content analysis as the process of perception, interpretation, and conceptualization of the internal meanings of qualitative data and mostly considers it an analysis method rather than a research method (6). Currently using qualitative research methods is increasing but the validity and quality of these studies have not been evaluated systematically and even have been neglected by the authors (7). So content analysis studies have always been explored by critics of qualitative studies. However the number of qualitative studies in the field of nursing is increasing and consequently, regarding their validity and quality is necessary (8, 9). So it is important that the authors would consider the validity of content analysis studies at three steps of preparation, organization and report the results and it is essential for them to regard the key points of these three steps to achieve a high content analysis study (7). Qualitative Articles Paper

At the preparation step, the most important challenges for validity are at three phases of Please cite this article in press as: Nassehi A, Esmaeili M, Varaei S. Quality in the qualitative content analysis studies. Nurs Pract Today. 2017; 4 (2):6 4-66 Quality in the qualitative content analysis Nursing Practice Today. 2017; 4(2):64-66. data gathering, sampling and selecting the appropriate units for data analysis. To increase the validity of the study at the data gathering phase, the information should be in line with the research questions (10). Another notable matter that must be considered by the researchers at the preparation step is sampling method and usually, the purposeful sampling method is used. In this method, the researcher must be informed about who has the best-needed information (11). To improve the quality of this phase, researchers should explain and describe a summary of their sampling method which includes the method of choosing the participants and the number of participants (12). Elo et al have mentioned that in qualitative content analysis studies, the sampling method is rarely explained (7) and it might damage their validity. Another important matter that must be regarded by the qualitative researchers is selecting the analysis units. Analysis unit could be a letter, a word, a part of a sentence or a few words. The most appropriate analysis unit is one that is large enough to cover the entire content and is small enough not to be extended outside the subject of thematic analysis. Providing sufficient transparent explanation about the manner of selecting the analysis units would improve the quality of content analysis studies (7). At the organization step, the researcher should explain the manner of formation of the concepts and categories so that the validity of the study could be evaluated. On the other hand, explanation and description of the concepts and their formation are facing challenges. One of these challenges is that some concepts could not be classified into any specific categories and some of the categories overlap each other (11). At this point, it is recommended that the content would be checked by two or more researchers (7). Holdford has stated that the result reporting step must be conducted 65 usefully and scientifically; while the most important part of qualitative content analysis studies, which is results reporting, has been neglected (13). Qualitative Articles Paper

Paying attention to the process of analysis and self-awareness would help correct reporting of the results at this step. Using images and table would also lead to clearer result presentation and improved quality of the study (7). Considering the mentioned issues, content analysis authors must have content analysis and self-criticism skills and should constantly have critical thinking and reconsideration during the analysis process of all of their analyses (14). Considering that, many researchers believe that content analysis method is a simple method, they would use this method widely and ignore its quality provision criteria. This could affect the validity of these studies (7). Based on the mentioned issues and to achieve quality in content analysis studies, regarding the evaluation criteria for this approach at all of the steps of the study is necessary. Content analysis authors must comprehensively explain and describe the steps of analysis and consider the limitations of their own studies and by enriching their information and considering the philosophical presupposition of content analysis, improve the quality of their study. References 1. Vaismoradi M, Turunen H and Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences 2013. 2. Noble H, Smith J. Issues of validity and reliability in qualitative research. EvidenceBased Nursing. 2015:ebnurs-2015-102054. 3. Adib Haj Bagheri M, Parvizi S, Salsali M. Qualitative Research Methods. Tehran : Boshra publication 2007. 4. Burns N, Grove S. The Practice of Nursing Research. 4 ed. Philadelphia Saunders; 2007.. Quality in the qualitative content analysis Nursing Practice Today. 2017; 4(2):64-66. 5. Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice: Lippincott Williams & Wilkins; 2008. 6. Zeighami R, Bagheri Nesami M SF. Haghdoost Oskouie SF, Yadavar Nikravesh M. Content Analysis. Iran Journal of Nursing .2008; 21(53). [Persian] 7. Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative content analysis: A focus on trustworthiness. Sage Open. 2014;4(1):2158244014522633. 8. Neuendorf K. Content analysis—A methodological primer for gender research. Sex Roles .2011; 64, 276-289 9. Baxter J. Content analysis. International encyclopedia of human geography .2007 ;1, 275-280. 10. Elo S & Kyngäs H. The qualitative content analysis process.Journal of Advanced Nursing. 2008; 62, 107-115. 11. Kyngäs H, Elo S, Pölkki T, Kääriäinen M & Kanste O. Sisällönanalyysi suomalaisessa hoitotieteellisessä tutkimuksessa[The use of content analysis in Finnish nursing scienceresearch]. Hoitotiede, 2011:; 23(2), 138-148. 12. Creswell, J. W. Qualitative inquiry and research design:Choosing among five approaches. Thousand Oaks, CA: Sage. 2013. 13. Holdford D. Content analysis methods for conducting research in social and administrative pharmacy. Research in Social & Administrative Pharmacy.2008; 4, 173181. 14. Thomas E & Magilvy J. KQualitative rigour or research validity in qualitative research. Qualitative Articles Paper

Journal for Specialists in Pediatric Nursing. 2011; 16, 151-155. 66 Copyright of Nursing Practice Today is the property of Tehran University of Medical Sciences and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. Hindawi BioMed Research International Volume 2017, Article ID 1064307, 9 pages https://doi.org/10.1155/2017/1064307 Research Article Towards a Better Understanding of Sickness Absence in Adolescence: A Qualitative Study among Dutch Intermediate Vocational Education Students Yvonne T. M. Vanneste,1,2,3 Frans J. M. Feron,3 Marlieke A. W. van Mook,1 and Angelique de Rijk3 1 Regional Public Health Service West Brabant, Tilburg, Netherlands Faculty of Social and Behavioural Sciences, Tranzo, Tilburg University, Tilburg, Netherlands 3 Department of Social Medicine, Faculty of Health, Medicine and Life Sciences, CAPHRI, Maastricht University, Maastricht, Netherlands 2 Correspondence should be addressed to Yvonne T. M. Vanneste; y.vanneste@ggdwestbrabant.nl Received 23 December 2016; Accepted 13 March 2017; Published 9 May 2017 Academic Editor: Arja R. Aro Copyright © 2017 Yvonne T. M. Vanneste et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. An adequate approach to sickness absence can reduce school dropout which is a major problem in Intermediate Vocational Education (IVE). This practice-based study explores the sickness absence reasons and factors influencing reporting the sickness, from a student’s perspective. Semistructured interviews were held until saturation. Data were collected and analysed by a multidisciplinary research team including youth health care physicians working with IVE students. The results show that, according to the students, reasons for sickness reporting were health-related or related to problems at home or in school. Students view their sickness absence as necessity, as asking for understanding, or as pardonable. Their views depended on (1) the perception of medical legitimacy, (2) feeling able to take their own responsibility, (3) feeling being taken seriously at school, and (4) the perception that the sickness reporting procedure at school is anonymous and easy. In conclusion, reporting sickness seems more a reaction to a necessity or opportunity than the result of a conscious decision-making process. Personalizing the sickness reporting procedures and demonstrating interest rather than control while discussing the sickness absence with the individual IVE student might very well affect their sickness absence levels. 1. Introduction School absenteeism is a major problem, both for the individual and for society. Qualitative Articles Paper

It may lead to a lower level of education and school dropout [1–3]. Low educational level and school dropout are both strongly associated with increased risk behaviour [4, 5], a higher prevalence of chronic health issues and common mental problems [6, 7], higher mortality rates [8–12], and an increased risk of social failure and delinquency [13, 14]. In the Netherlands, the prevalence of school dropout is highest at schools for Intermediate Vocational Education (abbreviated as IVE; ISCED 3C) [15]. In the school year 20112012, 71.5% of all school dropouts left school from IVE [16]. In particular, those dropouts with health problems (including mental health problems) appear to be subsequently less successful in their individual career development and lives [17, 18]. School absenteeism due to sickness reporting, also called sickness absence, is as common as truancy, or even more prevalent [19–22]. In the Netherlands, contrasting with the widespread implementation of sickness absenteeism prevention and guidance in the workplace, there are no interventions and agencies addressing sickness absence among students. Recently, the intervention “Medical Advice for Sickreported Students” (MASS) has been developed to address sickness absence in prevocational secondary and IVE schools [23–26]. MASS consists of a standardized approach by which schools, in direct collaboration with youth health care 2 BioMed Research International Weighing process Absence necessity (feeling sick or being ill) Reporting sick Sickness absence threshold Absence opportunities Need for absence (Organizational factors) (Personal factors) Figure 1: A model with aspects of the individual and workplace situation that are taken into account before reporting sick. Adapted from the decision model (Veerman, 1993). physicians, act upon student’s sickness reporting, followed by making and monitoring a management plan to optimize students’ health and maximize students’ participation in school activities. MASS is now tested in a limited number of schools and nominated to be implemented at a larger scale. However, the effects of MASS might improve, if communication with the students incorporates a better understanding of their perspective on the sickness absence. In the Netherlands, the IVE student is the key actor as he is required to report oneself sick. There are indications that what students report varies from what really happened. Derriks et al. [27] studied the reporting of absenteeism by IVE students and found that almost 40% of the students stated that they do not report their absence because it is rather easy to be absent from school unnoticed; 20% stated that if reporting their absence, they do not tell the real reason for absence. Qualitative Articles Paper

Recently, de Kroon et al. [28] found that students were much more convinced than the other stakeholders that sickness absence has most often medical reasons. When acting upon the student’s sickness reporting, as requested from schools using MASS, it therefore seems to be important to gain a better understanding of why and how IVE students report sick. Studies and models from occupational health are informative for this topic for two reasons. First, during work placements these students will also be expected to function as employees. Second, given their age, one should be able to appeal to their autonomy. Veerman’s model [29] is one of the many models for occupational absenteeism due to sickness [30]. The Veerman model (Figure 1) is a decisional model [30] and distinguishes different aspects of the individual and workplace situation that are taken into account before reporting sick. The model explains that “absence necessity” (i.e., feeling sick or being ill) is moderated by a “sickness absence threshold.” This threshold is in turn influenced by “absence opportunities” and “need for absence” (affected inversely by need to be present). “Absence opportunities” refer to organizational factors and legislation that allow for absence. “Need for absence” refers to the subjective values of the job and how much an employee wants to report sick due to the job. This model represents a two-stage process: there must be an absence necessity before a process of weighing pros and cons starts. This model can be used as a starting point to study IVE student perspectives on their sickness absence. However, the difference in age between these students and employees and the difference in relationships that exists between school and student versus that between employer and employee are elements for consideration. The research was thus inspired by observations in practice and by theoretical notions on sickness absence among adult employees. The purpose of this study was to gain insight into the specific dynamics of IVE students’ sickness reporting according to students themselves. This bottom-up practice-based knowledge of sickness absence in IVE students could make prevention and management of sickness absence among this group more effective [31]. The research questions for this study are as follows: (1) What are, according to the students, their reasons for sickness absence? (2) Which factors influence their sickness reporting according to the students? (3) To what extent does Veerman’s model apply to the sickness absence of IVE students? Qualitative Articles Paper

2. Methods Qualitative research methods are useful when exploring stakeholders’ perceptions [32]. To find answers to our research questions and to obtain proper insight into the experiences and perceptions of the students, in-depth individual semistructured interviewing was selected as the best method of data gathering [32, 33]. Data were collected between February and June 2014 in the North Brabant region in the southwest of the Netherlands. In order to obtain as many different views as possible, purposive sampling was used. Students who were especially knowledgeable about sickness absence and able to communicate their experiences and opinions in an expressive and reflective way were identified and selected [33]. Participants were approached until data saturation had been reached, meaning that no new data and concepts were identified [34]. BioMed Research International 3 Table 1: Overview of students’ characteristics. N. H. D. D. R. M. J. F. L. T. L. J. M. T. W. J. 1 Gender Male Male Female Female Male Female Male Male Female Male Female Male Female Male Female Male Age 20 24 20 19 18 17 19 18 17 19 19 21 19 23 19 22 Living at home Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Ethnicity Native Immigrant1 Native Native Native Native Native Native Native Native Native Native Native Native Native Native School 1 1 2 2 3 2 1 1 2 3 4 5 4 5 6 7 Sick reporting system Digital Digital By phone By phone By phone By phone Digital Digital By phone By phone By phone By phone By phone By phone By phone Digital Subject of education Architecture Architecture Legal services Legal services Entrepreneurship Legal services Architecture Architecture Legal services Entrepreneurship Teaching assistant Leisure Social care Branch manager Veterinary assistant Sports Second-generation immigrant. 2.1. Study Participants. To be included, students had to attend IVE and had to have experienced sickness absence. In the Netherlands, IVE has four educational levels. Level 4 is the highest level and gives access to institutes for Higher Vocational Education and Training [15]. Students were first asked to participate in the study by a care coordinator of the school. It appeared to be difficult to recruit students this way: only four students were willing to be interviewed. Then, by using the “chain-referral sampling” method [35], the next 12 students could be recruited. Because, in the beginning, only students who were receiving education at level 4 were willing to participate in the study, participation was eventually limited to this level. Qualitative Articles Paper

To obtain as many different views as possible, students with different background characteristics (gender, age, etc.) were searched for. Students to be interviewed were added until no additional new concepts were identified; saturation occurred after fourteen interviews and was confirmed through two final interviews. The participant characteristics are presented in Table 1. 2.2. Ethical Considerations. All procedures were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For both ethical and quality reasons, the study was conducted according to the Code of Conduct for Medical Research of the Council of the Dutch Federation of Medical Scientific Societies. Students were informed by letter about the purpose of the research, the anonymously processed data analysis, and the use of the information received, exclusively for research and in which confidentiality was guaranteed. They were made aware that they were free to refuse to participate at any time before, during, and after the interview. They were given three days for reflection before an appointment had to be made. The interview was only initiated upon receipt of written consent. In cases of being under the age of 18 years, written informed consent of the parents was also received. 2.3. Interview Procedure. The questions were broad, openended, and nondirective. The interview topic list was inspired by Veerman’s model and the experience of youth health care physicians and career counsellors in IVE. It included questions such as (a) why the student reported sick from school (from their perspective), followed by questions such as (b) what is the sickness reporting procedure in your school, (c) when and how do you report sick, (d) what happens after that, (e) who was involved in your sickness reporting, (f) how do your classmates deal with sickness reporting, and (g) from whom do you expect support after reporting sick? At the end of the interview the student was offered a conversation with the career counsellor or the youth health care physician. None of the respondents actually made use of this offer. The audio-recorded interviews lasted around 45 minutes, and were transcribed verbatim and anonymized for further analysis. 2.4. Analysis. An inductive thematic analysis was carried out [32] by structuring data, initial coding, categorizing experiences and perceptions, and identifying themes and their interrelations. In the multidisciplinary research team, different interpretations were discussed and refined until agreement was reached. To gain enhanced insight into the sickness absence, two researchers were youth health care physicians working in different practices (YV and FF), and one researcher was a sickness absence researcher (AdR). Several intermediate analyses were applied to check whether all topics had been covered. Qualitative Articles Paper

All data (transcripts, coding tree, and findings) was available for inspection by the coauthors during the 4 BioMed Research International research. In addition, a three-hour group meeting took place, in which a multidisciplinary team of career counsellors, youth health care physicians, and school attendance officers was asked whether they considered the findings to be clear, understandable, and logical. On the basis of this meeting the analysis was refined. 2.5. Availability of Supporting Data. The study data is stored by the Faculty of Social and Behavioural Sciences, Tranzo, Tilburg University, in The Netherlands following the institution’s data management policies. Data are fully available without restriction. 3. Results To begin with, three ways are found in which students view their absent periods: they regard their absence as (1) necessity, (2) asking for understanding, or (3) pardonable. These three views can be understood by varied background experiences: the degree to which they feel able to take responsibility for themselves; the degree to which the sick-reporting procedure at school is experienced as anonymous and (too) easy; and the degree to which they feel themselves to be taken seriously by the school. 3.1. How Students Regard Their Absence. When asking for the reason for sickness absence, all the students spontaneously gave a sort of “retrospective justification” for their sickness absence. Three views could be distinguished here. A first view was that of absence as necessity. The students found their sickness absence necessary and legitimate. They indicated that they report sick because they are sick or have physical complaints. I was sick two years ago. A problem with my nerves. And I missed eight months. (N., 20 y.) I had flu and a temperature. Yes, I did try, but it wasn’t on. So then I just went home. (D., 20 y.) A second view was that of absence as asking for understanding. The students excused themselves and asked for understanding for their sickness absence, because they were at a loss or were confused and upset. They expected that reporting sick will help them to feel better. They reported that psychological complaints and problems at home or at school made them report sick. I was much too occupied with myself, so then what’s the point of being at school?. . .And I explained that. I think I can expect allowance to be made for this. (D., 19 y.) If I need to calm down I report sick. (H., 24 y.) There is still a rather unpleasant atmosphere in the class. . . it puts very many students off, and then they sometimes simply report sick. (T., 19 y.) A third view was absence as pardonable. Then, the students regarded their reporting sick as pardonable and believed that school should not constrain them. Some of them blamed others for their sickness reporting and said that they occasionally reported sick because of reasons such as the following: other students reported also to go home, have free periods during the day, and complained about the noninspiring method of teaching. I think that many students think that a little bit of absence during school time is not really a problem. (F., 18 y.) If coming to school is just a waste of time, then you can expe…