examples of research topics in grounded theory

10 Grounded Theory Examples (Qualitative Research Method)

Grounded theory is a qualitative research method that involves the construction of theory from data rather than testing theories through data (Birks & Mills, 2015).

In other words, a grounded theory analysis doesn’t start with a hypothesis or theoretical framework, but instead generates a theory during the data analysis process .

This method has garnered a notable amount of attention since its inception in the 1960s by Barney Glaser and Anselm Strauss (Corbin & Strauss, 2015). 

Grounded Theory Definition and Overview

A central feature of grounded theory is the continuous interplay between data collection and analysis (Bringer, Johnston, & Brackenridge, 2016).

Grounded theorists start with the data, coding and considering each piece of collected information (for instance, behaviors collected during a psychological study).

As more information is collected, the researcher can reflect upon the data in an ongoing cycle where data informs an ever-growing and evolving theory (Mills, Bonner & Francis, 2017).

As such, the researcher isn’t tied to testing a hypothesis, but instead, can allow surprising and intriguing insights to emerge from the data itself.

Applications of grounded theory are widespread within the field of social sciences . The method has been utilized to provide insight into complex social phenomena such as nursing, education, and business management (Atkinson, 2015).

Grounded theory offers a sound methodology to unearth the complexities of social phenomena that aren’t well-understood in existing theories (McGhee, Marland & Atkinson, 2017).

While the methods of grounded theory can be labor-intensive and time-consuming, the rich, robust theories this approach produces make it a valuable tool in many researchers’ repertoires.

Real-Life Grounded Theory Examples

Title: A grounded theory analysis of older adults and information technology

Citation: Weatherall, J. W. A. (2000). A grounded theory analysis of older adults and information technology. Educational Gerontology , 26 (4), 371-386.

Description: This study employed a grounded theory approach to investigate older adults’ use of information technology (IT). Six participants from a senior senior were interviewed about their experiences and opinions regarding computer technology. Consistent with a grounded theory angle, there was no hypothesis to be tested. Rather, themes emerged out of the analysis process. From this, the findings revealed that the participants recognized the importance of IT in modern life, which motivated them to explore its potential. Positive attitudes towards IT were developed and reinforced through direct experience and personal ownership of technology.

Title: A taxonomy of dignity: a grounded theory study

Citation: Jacobson, N. (2009). A taxonomy of dignity: a grounded theory study. BMC International health and human rights , 9 (1), 1-9.

Description: This study aims to develop a taxonomy of dignity by letting the data create the taxonomic categories, rather than imposing the categories upon the analysis. The theory emerged from the textual and thematic analysis of 64 interviews conducted with individuals marginalized by health or social status , as well as those providing services to such populations and professionals working in health and human rights. This approach identified two main forms of dignity that emerged out of the data: “ human dignity ” and “social dignity”.

Title: A grounded theory of the development of noble youth purpose

Citation: Bronk, K. C. (2012). A grounded theory of the development of noble youth purpose. Journal of Adolescent Research , 27 (1), 78-109.

Description: This study explores the development of noble youth purpose over time using a grounded theory approach. Something notable about this study was that it returned to collect additional data two additional times, demonstrating how grounded theory can be an interactive process. The researchers conducted three waves of interviews with nine adolescents who demonstrated strong commitments to various noble purposes. The findings revealed that commitments grew slowly but steadily in response to positive feedback, with mentors and like-minded peers playing a crucial role in supporting noble purposes.

Title: A grounded theory of the flow experiences of Web users

Citation: Pace, S. (2004). A grounded theory of the flow experiences of Web users. International journal of human-computer studies , 60 (3), 327-363.

Description: This study attempted to understand the flow experiences of web users engaged in information-seeking activities, systematically gathering and analyzing data from semi-structured in-depth interviews with web users. By avoiding preconceptions and reviewing the literature only after the theory had emerged, the study aimed to develop a theory based on the data rather than testing preconceived ideas. The study identified key elements of flow experiences, such as the balance between challenges and skills, clear goals and feedback, concentration, a sense of control, a distorted sense of time, and the autotelic experience.

Title: Victimising of school bullying: a grounded theory

Citation: Thornberg, R., Halldin, K., Bolmsjö, N., & Petersson, A. (2013). Victimising of school bullying: A grounded theory. Research Papers in Education , 28 (3), 309-329.

Description: This study aimed to investigate the experiences of individuals who had been victims of school bullying and understand the effects of these experiences, using a grounded theory approach. Through iterative coding of interviews, the researchers identify themes from the data without a pre-conceived idea or hypothesis that they aim to test. The open-minded coding of the data led to the identification of a four-phase process in victimizing: initial attacks, double victimizing, bullying exit, and after-effects of bullying. The study highlighted the social processes involved in victimizing, including external victimizing through stigmatization and social exclusion, as well as internal victimizing through self-isolation, self-doubt, and lingering psychosocial issues.

Hypothetical Grounded Theory Examples

Suggested Title: “Understanding Interprofessional Collaboration in Emergency Medical Services”

Suggested Data Analysis Method: Coding and constant comparative analysis

How to Do It: This hypothetical study might begin with conducting in-depth interviews and field observations within several emergency medical teams to collect detailed narratives and behaviors. Multiple rounds of coding and categorizing would be carried out on this raw data, consistently comparing new information with existing categories. As the categories saturate, relationships among them would be identified, with these relationships forming the basis of a new theory bettering our understanding of collaboration in emergency settings. This iterative process of data collection, analysis, and theory development, continually refined based on fresh insights, upholds the essence of a grounded theory approach.

Suggested Title: “The Role of Social Media in Political Engagement Among Young Adults”

Suggested Data Analysis Method: Open, axial, and selective coding

Explanation: The study would start by collecting interaction data on various social media platforms, focusing on political discussions engaged in by young adults. Through open, axial, and selective coding, the data would be broken down, compared, and conceptualized. New insights and patterns would gradually form the basis of a theory explaining the role of social media in shaping political engagement, with continuous refinement informed by the gathered data. This process embodies the recursive essence of the grounded theory approach.

Suggested Title: “Transforming Workplace Cultures: An Exploration of Remote Work Trends”

Suggested Data Analysis Method: Constant comparative analysis

Explanation: The theoretical study could leverage survey data and in-depth interviews of employees and bosses engaging in remote work to understand the shifts in workplace culture. Coding and constant comparative analysis would enable the identification of core categories and relationships among them. Sustainability and resilience through remote ways of working would be emergent themes. This constant back-and-forth interplay between data collection, analysis, and theory formation aligns strongly with a grounded theory approach.

Suggested Title: “Persistence Amidst Challenges: A Grounded Theory Approach to Understanding Resilience in Urban Educators”

Suggested Data Analysis Method: Iterative Coding

How to Do It: This study would involve collecting data via interviews from educators in urban school systems. Through iterative coding, data would be constantly analyzed, compared, and categorized to derive meaningful theories about resilience. The researcher would constantly return to the data, refining the developing theory with every successive interaction. This procedure organically incorporates the grounded theory approach’s characteristic iterative nature.

Suggested Title: “Coping Strategies of Patients with Chronic Pain: A Grounded Theory Study”

Suggested Data Analysis Method: Line-by-line inductive coding

How to Do It: The study might initiate with in-depth interviews of patients who’ve experienced chronic pain. Line-by-line coding, followed by memoing, helps to immerse oneself in the data, utilizing a grounded theory approach to map out the relationships between categories and their properties. New rounds of interviews would supplement and refine the emergent theory further. The subsequent theory would then be a detailed, data-grounded exploration of how patients cope with chronic pain.

Grounded theory is an innovative way to gather qualitative data that can help introduce new thoughts, theories, and ideas into academic literature. While it has its strength in allowing the “data to do the talking”, it also has some key limitations – namely, often, it leads to results that have already been found in the academic literature. Studies that try to build upon current knowledge by testing new hypotheses are, in general, more laser-focused on ensuring we push current knowledge forward. Nevertheless, a grounded theory approach is very useful in many circumstances, revealing important new information that may not be generated through other approaches. So, overall, this methodology has great value for qualitative researchers, and can be extremely useful, especially when exploring specific case study projects . I also find it to synthesize well with action research projects .

Atkinson, P. (2015). Grounded theory and the constant comparative method: Valid qualitative research strategies for educators. Journal of Emerging Trends in Educational Research and Policy Studies, 6 (1), 83-86.

Birks, M., & Mills, J. (2015). Grounded theory: A practical guide . London: Sage.

Bringer, J. D., Johnston, L. H., & Brackenridge, C. H. (2016). Using computer-assisted qualitative data analysis software to develop a grounded theory project. Field Methods, 18 (3), 245-266.

Corbin, J., & Strauss, A. (2015). Basics of qualitative research: Techniques and procedures for developing grounded theory . Sage publications.

McGhee, G., Marland, G. R., & Atkinson, J. (2017). Grounded theory research: Literature reviewing and reflexivity. Journal of Advanced Nursing, 29 (3), 654-663.

Mills, J., Bonner, A., & Francis, K. (2017). Adopting a Constructivist Approach to Grounded Theory: Implications for Research Design. International Journal of Nursing Practice, 13 (2), 81-89.

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Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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Home » Grounded Theory – Methods, Examples and Guide

Grounded Theory – Methods, Examples and Guide

Table of Contents

Grounded Theory

Definition:

Grounded Theory is a qualitative research methodology that aims to generate theories based on data that are grounded in the empirical reality of the research context. The method involves a systematic process of data collection, coding, categorization, and analysis to identify patterns and relationships in the data.

The ultimate goal is to develop a theory that explains the phenomenon being studied, which is based on the data collected and analyzed rather than on preconceived notions or hypotheses. The resulting theory should be able to explain the phenomenon in a way that is consistent with the data and also accounts for variations and discrepancies in the data. Grounded Theory is widely used in sociology, psychology, management, and other social sciences to study a wide range of phenomena, such as organizational behavior, social interaction, and health care.

History of Grounded Theory

Grounded Theory was first introduced by sociologists Barney Glaser and Anselm Strauss in the 1960s as a response to the limitations of traditional positivist approaches to social research. The approach was initially developed to study dying patients and their families in hospitals, but it was soon applied to other areas of sociology and beyond.

Glaser and Strauss published their seminal book “The Discovery of Grounded Theory” in 1967, in which they presented their approach to developing theory from empirical data. They argued that existing social theories often did not account for the complexity and diversity of social phenomena, and that the development of theory should be grounded in empirical data.

Since then, Grounded Theory has become a widely used methodology in the social sciences, and has been applied to a wide range of topics, including healthcare, education, business, and psychology. The approach has also evolved over time, with variations such as constructivist grounded theory and feminist grounded theory being developed to address specific criticisms and limitations of the original approach.

Types of Grounded Theory

There are two main types of Grounded Theory: Classic Grounded Theory and Constructivist Grounded Theory.

Classic Grounded Theory

This approach is based on the work of Glaser and Strauss, and emphasizes the discovery of a theory that is grounded in data. The focus is on generating a theory that explains the phenomenon being studied, without being influenced by preconceived notions or existing theories. The process involves a continuous cycle of data collection, coding, and analysis, with the aim of developing categories and subcategories that are grounded in the data. The categories and subcategories are then compared and synthesized to generate a theory that explains the phenomenon.

Constructivist Grounded Theory

This approach is based on the work of Charmaz, and emphasizes the role of the researcher in the process of theory development. The focus is on understanding how individuals construct meaning and interpret their experiences, rather than on discovering an objective truth. The process involves a reflexive and iterative approach to data collection, coding, and analysis, with the aim of developing categories that are grounded in the data and the researcher’s interpretations of the data. The categories are then compared and synthesized to generate a theory that accounts for the multiple perspectives and interpretations of the phenomenon being studied.

Grounded Theory Conducting Guide

Here are some general guidelines for conducting a Grounded Theory study:

• Choose a research question: Start by selecting a research question that is open-ended and focuses on a specific social phenomenon or problem.
• Select participants and collect data: Identify a diverse group of participants who have experienced the phenomenon being studied. Use a variety of data collection methods such as interviews, observations, and document analysis to collect rich and diverse data.
• Analyze the data: Begin the process of analyzing the data using constant comparison. This involves comparing the data to each other and to existing categories and codes, in order to identify patterns and relationships. Use open coding to identify concepts and categories, and then use axial coding to organize them into a theoretical framework.
• Generate categories and codes: Generate categories and codes that describe the phenomenon being studied. Make sure that they are grounded in the data and that they accurately reflect the experiences of the participants.
• Refine and develop the theory: Use theoretical sampling to identify new data sources that are relevant to the developing theory. Use memoing to reflect on insights and ideas that emerge during the analysis process. Continue to refine and develop the theory until it provides a comprehensive explanation of the phenomenon.
• Validate the theory: Finally, seek to validate the theory by testing it against new data and seeking feedback from peers and other researchers. This process helps to refine and improve the theory, and to ensure that it is grounded in the data.
• Write up and disseminate the findings: Once the theory is fully developed and validated, write up the findings and disseminate them through academic publications and presentations. Make sure to acknowledge the contributions of the participants and to provide a detailed account of the research methods used.

Data Collection Methods

Grounded Theory Data Collection Methods are as follows:

• Interviews : One of the most common data collection methods in Grounded Theory is the use of in-depth interviews. Interviews allow researchers to gather rich and detailed data about the experiences, perspectives, and attitudes of participants. Interviews can be conducted one-on-one or in a group setting.
• Observation : Observation is another data collection method used in Grounded Theory. Researchers may observe participants in their natural settings, such as in a workplace or community setting. This method can provide insights into the social interactions and behaviors of participants.
• Document analysis: Grounded Theory researchers also use document analysis as a data collection method. This involves analyzing existing documents such as reports, policies, or historical records that are relevant to the phenomenon being studied.
• Focus groups : Focus groups involve bringing together a group of participants to discuss a specific topic or issue. This method can provide insights into group dynamics and social interactions.
• Fieldwork : Fieldwork involves immersing oneself in the research setting and participating in the activities of the participants. This method can provide an in-depth understanding of the culture and social dynamics of the research setting.
• Multimedia data: Grounded Theory researchers may also use multimedia data such as photographs, videos, or audio recordings to capture the experiences and perspectives of participants.

Data Analysis Methods

Grounded Theory Data Analysis Methods are as follows:

• Open coding: Open coding is the process of identifying concepts and categories in the data. Researchers use open coding to assign codes to different pieces of data, and to identify similarities and differences between them.
• Axial coding: Axial coding is the process of organizing the codes into broader categories and subcategories. Researchers use axial coding to develop a theoretical framework that explains the phenomenon being studied.
• Constant comparison: Grounded Theory involves a process of constant comparison, in which data is compared to each other and to existing categories and codes in order to identify patterns and relationships.
• Theoretical sampling: Theoretical sampling involves selecting new data sources based on the emerging theory. Researchers use theoretical sampling to collect data that will help refine and validate the theory.
• Memoing : Memoing involves writing down reflections, insights, and ideas as the analysis progresses. This helps researchers to organize their thoughts and develop a deeper understanding of the data.
• Peer debriefing: Peer debriefing involves seeking feedback from peers and other researchers on the developing theory. This process helps to validate the theory and ensure that it is grounded in the data.
• Member checking: Member checking involves sharing the emerging theory with the participants in the study and seeking their feedback. This process helps to ensure that the theory accurately reflects the experiences and perspectives of the participants.
• Triangulation: Triangulation involves using multiple sources of data to validate the emerging theory. Researchers may use different data collection methods, different data sources, or different analysts to ensure that the theory is grounded in the data.

Applications of Grounded Theory

Here are some of the key applications of Grounded Theory:

• Social sciences : Grounded Theory is widely used in social science research, particularly in fields such as sociology, psychology, and anthropology. It can be used to explore a wide range of social phenomena, such as social interactions, power dynamics, and cultural practices.
• Healthcare : Grounded Theory can be used in healthcare research to explore patient experiences, healthcare practices, and healthcare systems. It can provide insights into the factors that influence healthcare outcomes, and can inform the development of interventions and policies.
• Education : Grounded Theory can be used in education research to explore teaching and learning processes, student experiences, and educational policies. It can provide insights into the factors that influence educational outcomes, and can inform the development of educational interventions and policies.
• Business : Grounded Theory can be used in business research to explore organizational processes, management practices, and consumer behavior. It can provide insights into the factors that influence business outcomes, and can inform the development of business strategies and policies.
• Technology : Grounded Theory can be used in technology research to explore user experiences, technology adoption, and technology design. It can provide insights into the factors that influence technology outcomes, and can inform the development of technology interventions and policies.

Examples of Grounded Theory

Examples of Grounded Theory in different case studies are as follows:

• Glaser and Strauss (1965): This study, which is considered one of the foundational works of Grounded Theory, explored the experiences of dying patients in a hospital. The researchers used Grounded Theory to develop a theoretical framework that explained the social processes of dying, and that was grounded in the data.
• Charmaz (1983): This study explored the experiences of chronic illness among young adults. The researcher used Grounded Theory to develop a theoretical framework that explained how individuals with chronic illness managed their illness, and how their illness impacted their sense of self.
• Strauss and Corbin (1990): This study explored the experiences of individuals with chronic pain. The researchers used Grounded Theory to develop a theoretical framework that explained the different strategies that individuals used to manage their pain, and that was grounded in the data.
• Glaser and Strauss (1967): This study explored the experiences of individuals who were undergoing a process of becoming disabled. The researchers used Grounded Theory to develop a theoretical framework that explained the social processes of becoming disabled, and that was grounded in the data.
• Clarke (2005): This study explored the experiences of patients with cancer who were receiving chemotherapy. The researcher used Grounded Theory to develop a theoretical framework that explained the factors that influenced patient adherence to chemotherapy, and that was grounded in the data.

Grounded Theory Research Example

A Grounded Theory Research Example Would be:

Research question : What is the experience of first-generation college students in navigating the college admission process?

Data collection : The researcher conducted interviews with first-generation college students who had recently gone through the college admission process. The interviews were audio-recorded and transcribed verbatim.

Data analysis: The researcher used a constant comparative method to analyze the data. This involved coding the data, comparing codes, and constantly revising the codes to identify common themes and patterns. The researcher also used memoing, which involved writing notes and reflections on the data and analysis.

Findings : Through the analysis of the data, the researcher identified several themes related to the experience of first-generation college students in navigating the college admission process, such as feeling overwhelmed by the complexity of the process, lacking knowledge about the process, and facing financial barriers.

Theory development: Based on the findings, the researcher developed a theory about the experience of first-generation college students in navigating the college admission process. The theory suggested that first-generation college students faced unique challenges in the college admission process due to their lack of knowledge and resources, and that these challenges could be addressed through targeted support programs and resources.

In summary, grounded theory research involves collecting data, analyzing it through constant comparison and memoing, and developing a theory grounded in the data. The resulting theory can help to explain the phenomenon being studied and guide future research and interventions.

Purpose of Grounded Theory

The purpose of Grounded Theory is to develop a theoretical framework that explains a social phenomenon, process, or interaction. This theoretical framework is developed through a rigorous process of data collection, coding, and analysis, and is grounded in the data.

Grounded Theory aims to uncover the social processes and patterns that underlie social phenomena, and to develop a theoretical framework that explains these processes and patterns. It is a flexible method that can be used to explore a wide range of research questions and settings, and is particularly well-suited to exploring complex social phenomena that have not been well-studied.

The ultimate goal of Grounded Theory is to generate a theoretical framework that is grounded in the data, and that can be used to explain and predict social phenomena. This theoretical framework can then be used to inform policy and practice, and to guide future research in the field.

When to use Grounded Theory

Following are some situations in which Grounded Theory may be particularly useful:

• Exploring new areas of research: Grounded Theory is particularly useful when exploring new areas of research that have not been well-studied. By collecting and analyzing data, researchers can develop a theoretical framework that explains the social processes and patterns underlying the phenomenon of interest.
• Studying complex social phenomena: Grounded Theory is well-suited to exploring complex social phenomena that involve multiple social processes and interactions. By using an iterative process of data collection and analysis, researchers can develop a theoretical framework that explains the complexity of the social phenomenon.
• Generating hypotheses: Grounded Theory can be used to generate hypotheses about social processes and interactions that can be tested in future research. By developing a theoretical framework that explains a social phenomenon, researchers can identify areas for further research and hypothesis testing.
• Informing policy and practice : Grounded Theory can provide insights into the factors that influence social phenomena, and can inform policy and practice in a variety of fields. By developing a theoretical framework that explains a social phenomenon, researchers can identify areas for intervention and policy development.

Characteristics of Grounded Theory

Grounded Theory is a qualitative research method that is characterized by several key features, including:

• Emergence : Grounded Theory emphasizes the emergence of theoretical categories and concepts from the data, rather than preconceived theoretical ideas. This means that the researcher does not start with a preconceived theory or hypothesis, but instead allows the theory to emerge from the data.
• Iteration : Grounded Theory is an iterative process that involves constant comparison of data and analysis, with each round of data collection and analysis refining the theoretical framework.
• Inductive : Grounded Theory is an inductive method of analysis, which means that it derives meaning from the data. The researcher starts with the raw data and systematically codes and categorizes it to identify patterns and themes, and to develop a theoretical framework that explains these patterns.
• Reflexive : Grounded Theory requires the researcher to be reflexive and self-aware throughout the research process. The researcher’s personal biases and assumptions must be acknowledged and addressed in the analysis process.
• Holistic : Grounded Theory takes a holistic approach to data analysis, looking at the entire data set rather than focusing on individual data points. This allows the researcher to identify patterns and themes that may not be apparent when looking at individual data points.
• Contextual : Grounded Theory emphasizes the importance of understanding the context in which social phenomena occur. This means that the researcher must consider the social, cultural, and historical factors that may influence the phenomenon of interest.

Advantages of Grounded Theory

Advantages of Grounded Theory are as follows:

• Flexibility : Grounded Theory is a flexible method that can be used to explore a wide range of research questions and settings. It is particularly well-suited to exploring complex social phenomena that have not been well-studied.
• Validity : Grounded Theory aims to develop a theoretical framework that is grounded in the data, which enhances the validity and reliability of the research findings. The iterative process of data collection and analysis also helps to ensure that the research findings are reliable and robust.
• Originality : Grounded Theory can generate new and original insights into social phenomena, as it is not constrained by preconceived theoretical ideas or hypotheses. This allows researchers to explore new areas of research and generate new theoretical frameworks.
• Real-world relevance: Grounded Theory can inform policy and practice, as it provides insights into the factors that influence social phenomena. The theoretical frameworks developed through Grounded Theory can be used to inform policy development and intervention strategies.
• Ethical : Grounded Theory is an ethical research method, as it allows participants to have a voice in the research process. Participants’ perspectives are central to the data collection and analysis process, which ensures that their views are taken into account.
• Replication : Grounded Theory is a replicable method of research, as the theoretical frameworks developed through Grounded Theory can be tested and validated in future research.

Limitations of Grounded Theory

Limitations of Grounded Theory are as follows:

• Time-consuming: Grounded Theory can be a time-consuming method, as the iterative process of data collection and analysis requires significant time and effort. This can make it difficult to conduct research in a timely and cost-effective manner.
• Subjectivity : Grounded Theory is a subjective method, as the researcher’s personal biases and assumptions can influence the data analysis process. This can lead to potential issues with reliability and validity of the research findings.
• Generalizability : Grounded Theory is a context-specific method, which means that the theoretical frameworks developed through Grounded Theory may not be generalizable to other contexts or populations. This can limit the applicability of the research findings.
• Lack of structure : Grounded Theory is an exploratory method, which means that it lacks the structure of other research methods, such as surveys or experiments. This can make it difficult to compare findings across different studies.
• Data overload: Grounded Theory can generate a large amount of data, which can be overwhelming for researchers. This can make it difficult to manage and analyze the data effectively.
• Difficulty in publication: Grounded Theory can be challenging to publish in some academic journals, as some reviewers and editors may view it as less rigorous than other research methods.

About the author

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Researcher, Academic Writer, Web developer

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• Correspondence
• Open access
• Published: 09 September 2011

How to do a grounded theory study: a worked example of a study of dental practices

• Alexandra Sbaraini 1 , 2 ,
• Stacy M Carter 1 ,
• R Wendell Evans 2 &
• Anthony Blinkhorn 1 , 2  

BMC Medical Research Methodology volume  11 , Article number:  128 ( 2011 ) Cite this article

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Qualitative methodologies are increasingly popular in medical research. Grounded theory is the methodology most-often cited by authors of qualitative studies in medicine, but it has been suggested that many 'grounded theory' studies are not concordant with the methodology. In this paper we provide a worked example of a grounded theory project. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

We documented a worked example of using grounded theory methodology in practice.

We describe our sampling, data collection, data analysis and interpretation. We explain how these steps were consistent with grounded theory methodology, and show how they related to one another. Grounded theory methodology assisted us to develop a detailed model of the process of adapting preventive protocols into dental practice, and to analyse variation in this process in different dental practices.

Conclusions

By employing grounded theory methodology rigorously, medical researchers can better design and justify their methods, and produce high-quality findings that will be more useful to patients, professionals and the research community.

Peer Review reports

Qualitative research is increasingly popular in health and medicine. In recent decades, qualitative researchers in health and medicine have founded specialist journals, such as Qualitative Health Research , established 1991, and specialist conferences such as the Qualitative Health Research conference of the International Institute for Qualitative Methodology, established 1994, and the Global Congress for Qualitative Health Research, established 2011 [ 1 – 3 ]. Journals such as the British Medical Journal have published series about qualitative methodology (1995 and 2008) [ 4 , 5 ]. Bodies overseeing human research ethics, such as the Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, and the Australian National Statement on Ethical Conduct in Human Research [ 6 , 7 ], have included chapters or sections on the ethics of qualitative research. The increasing popularity of qualitative methodologies for medical research has led to an increasing awareness of formal qualitative methodologies. This is particularly so for grounded theory, one of the most-cited qualitative methodologies in medical research [[ 8 ], p47].

Grounded theory has a chequered history [ 9 ]. Many authors label their work 'grounded theory' but do not follow the basics of the methodology [ 10 , 11 ]. This may be in part because there are few practical examples of grounded theory in use in the literature. To address this problem, we will provide a brief outline of the history and diversity of grounded theory methodology, and a worked example of the methodology in practice. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

The history, diversity and basic components of 'grounded theory' methodology and method

Founded on the seminal 1967 book 'The Discovery of Grounded Theory' [ 12 ], the grounded theory tradition is now diverse and somewhat fractured, existing in four main types, with a fifth emerging. Types one and two are the work of the original authors: Barney Glaser's 'Classic Grounded Theory' [ 13 ] and Anselm Strauss and Juliet Corbin's 'Basics of Qualitative Research' [ 14 ]. Types three and four are Kathy Charmaz's 'Constructivist Grounded Theory' [ 15 ] and Adele Clarke's postmodern Situational Analysis [ 16 ]: Charmaz and Clarke were both students of Anselm Strauss. The fifth, emerging variant is 'Dimensional Analysis' [ 17 ] which is being developed from the work of Leonard Schaztman, who was a colleague of Strauss and Glaser in the 1960s and 1970s.

There has been some discussion in the literature about what characteristics a grounded theory study must have to be legitimately referred to as 'grounded theory' [ 18 ]. The fundamental components of a grounded theory study are set out in Table 1 . These components may appear in different combinations in other qualitative studies; a grounded theory study should have all of these. As noted, there are few examples of 'how to do' grounded theory in the literature [ 18 , 19 ]. Those that do exist have focused on Strauss and Corbin's methods [ 20 – 25 ]. An exception is Charmaz's own description of her study of chronic illness [ 26 ]; we applied this same variant in our study. In the remainder of this paper, we will show how each of the characteristics of grounded theory methodology worked in our study of dental practices.

Study background

We used grounded theory methodology to investigate social processes in private dental practices in New South Wales (NSW), Australia. This grounded theory study builds on a previous Australian Randomized Controlled Trial (RCT) called the Monitor Dental Practice Program (MPP) [ 27 ]. We know that preventive techniques can arrest early tooth decay and thus reduce the need for fillings [ 28 – 32 ]. Unfortunately, most dentists worldwide who encounter early tooth decay continue to drill it out and fill the tooth [ 33 – 37 ]. The MPP tested whether dentists could increase their use of preventive techniques. In the intervention arm, dentists were provided with a set of evidence-based preventive protocols to apply [ 38 ]; control practices provided usual care. The MPP protocols used in the RCT guided dentists to systematically apply preventive techniques to prevent new tooth decay and to arrest early stages of tooth decay in their patients, therefore reducing the need for drilling and filling. The protocols focused on (1) primary prevention of new tooth decay (tooth brushing with high concentration fluoride toothpaste and dietary advice) and (2) intensive secondary prevention through professional treatment to arrest tooth decay progress (application of fluoride varnish, supervised monitoring of dental plaque control and clinical outcomes)[ 38 ].

As the RCT unfolded, it was discovered that practices in the intervention arm were not implementing the preventive protocols uniformly. Why had the outcomes of these systematically implemented protocols been so different? This question was the starting point for our grounded theory study. We aimed to understand how the protocols had been implemented, including the conditions and consequences of variation in the process. We hoped that such understanding would help us to see how the norms of Australian private dental practice as regards to tooth decay could be moved away from drilling and filling and towards evidence-based preventive care.

Designing this grounded theory study

Figure 1 illustrates the steps taken during the project that will be described below from points A to F.

Study design . file containing a figure illustrating the study design.

A. An open beginning and research questions

Grounded theory studies are generally focused on social processes or actions: they ask about what happens and how people interact . This shows the influence of symbolic interactionism, a social psychological approach focused on the meaning of human actions [ 39 ]. Grounded theory studies begin with open questions, and researchers presume that they may know little about the meanings that drive the actions of their participants. Accordingly, we sought to learn from participants how the MPP process worked and how they made sense of it. We wanted to answer a practical social problem: how do dentists persist in drilling and filling early stages of tooth decay, when they could be applying preventive care?

We asked research questions that were open, and focused on social processes. Our initial research questions were:

What was the process of implementing (or not-implementing) the protocols (from the perspective of dentists, practice staff, and patients)?

How did this process vary?

B. Ethics approval and ethical issues

In our experience, medical researchers are often concerned about the ethics oversight process for such a flexible, unpredictable study design. We managed this process as follows. Initial ethics approval was obtained from the Human Research Ethics Committee at the University of Sydney. In our application, we explained grounded theory procedures, in particular the fact that they evolve. In our initial application we provided a long list of possible recruitment strategies and interview questions, as suggested by Charmaz [ 15 ]. We indicated that we would make future applications to modify our protocols. We did this as the study progressed - detailed below. Each time we reminded the committee that our study design was intended to evolve with ongoing modifications. Each modification was approved without difficulty. As in any ethical study, we ensured that participation was voluntary, that participants could withdraw at any time, and that confidentiality was protected. All responses were anonymised before analysis, and we took particular care not to reveal potentially identifying details of places, practices or clinicians.

C. Initial, Purposive Sampling (before theoretical sampling was possible)

Grounded theory studies are characterised by theoretical sampling, but this requires some data to be collected and analysed. Sampling must thus begin purposively, as in any qualitative study. Participants in the previous MPP study provided our population [ 27 ]. The MPP included 22 private dental practices in NSW, randomly allocated to either the intervention or control group. With permission of the ethics committee; we sent letters to the participants in the MPP, inviting them to participate in a further qualitative study. From those who agreed, we used the quantitative data from the MPP to select an initial sample.

Then, we selected the practice in which the most dramatic results had been achieved in the MPP study (Dental Practice 1). This was a purposive sampling strategy, to give us the best possible access to the process of successfully implementing the protocols. We interviewed all consenting staff who had been involved in the MPP (one dentist, five dental assistants). We then recruited 12 patients who had been enrolled in the MPP, based on their clinically measured risk of developing tooth decay: we selected some patients whose risk status had gotten better, some whose risk had worsened and some whose risk had stayed the same. This purposive sample was designed to provide maximum variation in patients' adoption of preventive dental care.

Initial Interviews

One hour in-depth interviews were conducted. The researcher/interviewer (AS) travelled to a rural town in NSW where interviews took place. The initial 18 participants (one dentist, five dental assistants and 12 patients) from Dental Practice 1 were interviewed in places convenient to them such as the dental practice, community centres or the participant's home.

Two initial interview schedules were designed for each group of participants: 1) dentists and dental practice staff and 2) dental patients. Interviews were semi-structured and based loosely on the research questions. The initial questions for dentists and practice staff are in Additional file 1 . Interviews were digitally recorded and professionally transcribed. The research location was remote from the researcher's office, thus data collection was divided into two episodes to allow for intermittent data analysis. Dentist and practice staff interviews were done in one week. The researcher wrote memos throughout this week. The researcher then took a month for data analysis in which coding and memo-writing occurred. Then during a return visit, patient interviews were completed, again with memo-writing during the data-collection period.

D. Data Analysis

Coding and the constant comparative method.

Coding is essential to the development of a grounded theory [ 15 ]. According to Charmaz [[ 15 ], p46], 'coding is the pivotal link between collecting data and developing an emergent theory to explain these data. Through coding, you define what is happening in the data and begin to grapple with what it means'. Coding occurs in stages. In initial coding, the researcher generates as many ideas as possible inductively from early data. In focused coding, the researcher pursues a selected set of central codes throughout the entire dataset and the study. This requires decisions about which initial codes are most prevalent or important, and which contribute most to the analysis. In theoretical coding, the researcher refines the final categories in their theory and relates them to one another. Charmaz's method, like Glaser's method [ 13 ], captures actions or processes by using gerunds as codes (verbs ending in 'ing'); Charmaz also emphasises coding quickly, and keeping the codes as similar to the data as possible.

We developed our coding systems individually and through team meetings and discussions.

We have provided a worked example of coding in Table 2 . Gerunds emphasise actions and processes. Initial coding identifies many different processes. After the first few interviews, we had a large amount of data and many initial codes. This included a group of codes that captured how dentists sought out evidence when they were exposed to a complex clinical case, a new product or technique. Because this process seemed central to their practice, and because it was talked about often, we decided that seeking out evidence should become a focused code. By comparing codes against codes and data against data, we distinguished the category of "seeking out evidence" from other focused codes, such as "gathering and comparing peers' evidence to reach a conclusion", and we understood the relationships between them. Using this constant comparative method (see Table 1 ), we produced a theoretical code: "making sense of evidence and constructing knowledge". This code captured the social process that dentists went through when faced with new information or a practice challenge. This theoretical code will be the focus of a future paper.

Memo-writing

Throughout the study, we wrote extensive case-based memos and conceptual memos. After each interview, the interviewer/researcher (AS) wrote a case-based memo reflecting on what she learned from that interview. They contained the interviewer's impressions about the participants' experiences, and the interviewer's reactions; they were also used to systematically question some of our pre-existing ideas in relation to what had been said in the interview. Table 3 illustrates one of those memos. After a few interviews, the interviewer/researcher also began making and recording comparisons among these memos.

We also wrote conceptual memos about the initial codes and focused codes being developed, as described by Charmaz [ 15 ]. We used these memos to record our thinking about the meaning of codes and to record our thinking about how and when processes occurred, how they changed, and what their consequences were. In these memos, we made comparisons between data, cases and codes in order to find similarities and differences, and raised questions to be answered in continuing interviews. Table 4 illustrates a conceptual memo.

At the end of our data collection and analysis from Dental Practice 1, we had developed a tentative model of the process of implementing the protocols, from the perspective of dentists, dental practice staff and patients. This was expressed in both diagrams and memos, was built around a core set of focused codes, and illustrated relationships between them.

E. Theoretical sampling, ongoing data analysis and alteration of interview route

We have already described our initial purposive sampling. After our initial data collection and analysis, we used theoretical sampling (see Table 1 ) to determine who to sample next and what questions to ask during interviews. We submitted Ethics Modification applications for changes in our question routes, and had no difficulty with approval. We will describe how the interview questions for dentists and dental practice staff evolved, and how we selected new participants to allow development of our substantive theory. The patients' interview schedule and theoretical sampling followed similar procedures.

Evolution of theoretical sampling and interview questions

We now had a detailed provisional model of the successful process implemented in Dental Practice 1. Important core focused codes were identified, including practical/financial, historical and philosophical dimensions of the process. However, we did not yet understand how the process might vary or go wrong, as implementation in the first practice we studied had been described as seamless and beneficial for everyone. Because our aim was to understand the process of implementing the protocols, including the conditions and consequences of variation in the process, we needed to understand how implementation might fail. For this reason, we theoretically sampled participants from Dental Practice 2, where uptake of the MPP protocols had been very limited according to data from the RCT trial.

We also changed our interview questions based on the analysis we had already done (see Additional file 2 ). In our analysis of data from Dental Practice 1, we had learned that "effectiveness" of treatments and "evidence" both had a range of meanings. We also learned that new technologies - in particular digital x-rays and intra-oral cameras - had been unexpectedly important to the process of implementing the protocols. For this reason, we added new questions for the interviews in Dental Practice 2 to directly investigate "effectiveness", "evidence" and how dentists took up new technologies in their practice.

Then, in Dental Practice 2 we learned more about the barriers dentists and practice staff encountered during the process of implementing the MPP protocols. We confirmed and enriched our understanding of dentists' processes for adopting technology and producing knowledge, dealing with complex cases and we further clarified the concept of evidence. However there was a new, important, unexpected finding in Dental Practice 2. Dentists talked about "unreliable" patients - that is, patients who were too unreliable to have preventive dental care offered to them. This seemed to be a potentially important explanation for non-implementation of the protocols. We modified our interview schedule again to include questions about this concept (see Additional file 3 ) leading to another round of ethics approvals. We also returned to Practice 1 to ask participants about the idea of an "unreliable" patient.

Dentists' construction of the "unreliable" patient during interviews also prompted us to theoretically sample for "unreliable" and "reliable" patients in the following round of patients' interviews. The patient question route was also modified by the analysis of the dentists' and practice staff data. We wanted to compare dentists' perspectives with the perspectives of the patients themselves. Dentists were asked to select "reliable" and "unreliable" patients to be interviewed. Patients were asked questions about what kind of services dentists should provide and what patients valued when coming to the dentist. We found that these patients (10 reliable and 7 unreliable) talked in very similar ways about dental care. This finding suggested to us that some deeply-held assumptions within the dental profession may not be shared by dental patients.

At this point, we decided to theoretically sample dental practices from the non-intervention arm of the MPP study. This is an example of the 'openness' of a grounded theory study potentially subtly shifting the focus of the study. Our analysis had shifted our focus: rather than simply studying the process of implementing the evidence-based preventive protocols, we were studying the process of doing prevention in private dental practice. All participants seemed to be revealing deeply held perspectives shared in the dental profession, whether or not they were providing dental care as outlined in the MPP protocols. So, by sampling dentists from both intervention and control group from the previous MPP study, we aimed to confirm or disconfirm the broader reach of our emerging theory and to complete inductive development of key concepts. Theoretical sampling added 12 face to face interviews and 10 telephone interviews to the data. A total of 40 participants between the ages of 18 and 65 were recruited. Telephone interviews were of comparable length, content and quality to face to face interviews, as reported elsewhere in the literature [ 40 ].

F. Mapping concepts, theoretical memo writing and further refining of concepts

After theoretical sampling, we could begin coding theoretically. We fleshed out each major focused code, examining the situations in which they appeared, when they changed and the relationship among them. At time of writing, we have reached theoretical saturation (see Table 1 ). We have been able to determine this in several ways. As we have become increasingly certain about our central focused codes, we have re-examined the data to find all available insights regarding those codes. We have drawn diagrams and written memos. We have looked rigorously for events or accounts not explained by the emerging theory so as to develop it further to explain all of the data. Our theory, which is expressed as a set of concepts that are related to one another in a cohesive way, now accounts adequately for all the data we have collected. We have presented the developing theory to specialist dental audiences and to the participants, and have found that it was accepted by and resonated with these audiences.

We have used these procedures to construct a detailed, multi-faceted model of the process of incorporating prevention into private general dental practice. This model includes relationships among concepts, consequences of the process, and variations in the process. A concrete example of one of our final key concepts is the process of "adapting to" prevention. More commonly in the literature writers speak of adopting, implementing or translating evidence-based preventive protocols into practice. Through our analysis, we concluded that what was required was 'adapting to' those protocols in practice. Some dental practices underwent a slow process of adapting evidence-based guidance to their existing practice logistics. Successful adaptation was contingent upon whether (1) the dentist-in-charge brought the whole dental team together - including other dentists - and got everyone interested and actively participating during preventive activities; (2) whether the physical environment of the practice was re-organised around preventive activities, (3) whether the dental team was able to devise new and efficient routines to accommodate preventive activities, and (4) whether the fee schedule was amended to cover the delivery of preventive services, which hitherto was considered as "unproductive time".

Adaptation occurred over time and involved practical, historical and philosophical aspects of dental care. Participants transitioned from their initial state - selling restorative care - through an intermediary stage - learning by doing and educating patients about the importance of preventive care - and finally to a stage where they were offering patients more than just restorative care. These are examples of ways in which participants did not simply adopt protocols in a simple way, but needed to adapt the protocols and their own routines as they moved toward more preventive practice.

The quality of this grounded theory study

There are a number of important assurances of quality in keeping with grounded theory procedures and general principles of qualitative research. The following points describe what was crucial for this study to achieve quality.

During data collection

1. All interviews were digitally recorded, professionally transcribed in detail and the transcripts checked against the recordings.

2. We analysed the interview transcripts as soon as possible after each round of interviews in each dental practice sampled as shown on Figure 1 . This allowed the process of theoretical sampling to occur.

3. Writing case-based memos right after each interview while being in the field allowed the researcher/interviewer to capture initial ideas and make comparisons between participants' accounts. These memos assisted the researcher to make comparison among her reflections, which enriched data analysis and guided further data collection.

4. Having the opportunity to contact participants after interviews to clarify concepts and to interview some participants more than once contributed to the refinement of theoretical concepts, thus forming part of theoretical sampling.

5. The decision to include phone interviews due to participants' preference worked very well in this study. Phone interviews had similar length and depth compared to the face to face interviews, but allowed for a greater range of participation.

During data analysis

1. Detailed analysis records were kept; which made it possible to write this explanatory paper.

2. The use of the constant comparative method enabled the analysis to produce not just a description but a model, in which more abstract concepts were related and a social process was explained.

3. All researchers supported analysis activities; a regular meeting of the research team was convened to discuss and contextualize emerging interpretations, introducing a wide range of disciplinary perspectives.

Answering our research questions

We developed a detailed model of the process of adapting preventive protocols into dental practice, and analysed the variation in this process in different dental practices. Transferring evidence-based preventive protocols into these dental practices entailed a slow process of adapting the evidence to the existing practices logistics. Important practical, philosophical and historical elements as well as barriers and facilitators were present during a complex adaptation process. Time was needed to allow dentists and practice staff to go through this process of slowly adapting their practices to this new way of working. Patients also needed time to incorporate home care activities and more frequent visits to dentists into their daily routines. Despite being able to adapt or not, all dentists trusted the concrete clinical evidence that they have produced, that is, seeing results in their patients mouths made them believe in a specific treatment approach.

Concluding remarks

This paper provides a detailed explanation of how a study evolved using grounded theory methodology (GTM), one of the most commonly used methodologies in qualitative health and medical research [[ 8 ], p47]. In 2007, Bryant and Charmaz argued:

'Use of GTM, at least as much as any other research method, only develops with experience. Hence the failure of all those attempts to provide clear, mechanistic rules for GTM: there is no 'GTM for dummies'. GTM is based around heuristics and guidelines rather than rules and prescriptions. Moreover, researchers need to be familiar with GTM, in all its major forms, in order to be able to understand how they might adapt it in use or revise it into new forms and variations.' [[ 8 ], p17].

Our detailed explanation of our experience in this grounded theory study is intended to provide, vicariously, the kind of 'experience' that might help other qualitative researchers in medicine and health to apply and benefit from grounded theory methodology in their studies. We hope that our explanation will assist others to avoid using grounded theory as an 'approving bumper sticker' [ 10 ], and instead use it as a resource that can greatly improve the quality and outcome of a qualitative study.

Abbreviations

grounded theory methods

Monitor Dental Practice Program

New South Wales

Randomized Controlled Trial.

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Acknowledgements

We thank dentists, dental practice staff and patients for their invaluable contributions to the study. We thank Emeritus Professor Miles Little for his time and wise comments during the project.

The authors received financial support for the research from the following funding agencies: University of Sydney Postgraduate Award 2009; The Oral Health Foundation, University of Sydney; Dental Board New South Wales; Australian Dental Research Foundation; National Health and Medical Research Council Project Grant 632715.

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Alexandra Sbaraini, Stacy M Carter & Anthony Blinkhorn

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Authors' contributions

All authors have made substantial contributions to conception and design of this study. AS carried out data collection, analysis, and interpretation of data. SMC made substantial contribution during data collection, analysis and data interpretation. AS, SMC, RWE, and AB have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.

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Additional file 1: Initial interview schedule for dentists and dental practice staff. file containing initial interview schedule for dentists and dental practice staff. (DOC 30 KB)

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Additional file 2: Questions added to the initial interview schedule for dentists and dental practice staff. file containing questions added to the initial interview schedule (DOC 26 KB)

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Additional file 3: Questions added to the modified interview schedule for dentists and dental practice staff. file containing questions added to the modified interview schedule (DOC 26 KB)

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Sbaraini, A., Carter, S.M., Evans, R.W. et al. How to do a grounded theory study: a worked example of a study of dental practices. BMC Med Res Methodol 11 , 128 (2011). https://doi.org/10.1186/1471-2288-11-128

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Your complete guide to grounded theory research.

11 min read If you have an area of interest, but no hypothesis yet, try grounded theory research. You conduct data collection and analysis, forming a theory based on facts. Read our ultimate guide for everything you need to know.

What is grounded theory in research?

Grounded theory is a systematic qualitative research method that collects empirical data first, and then creates a theory ‘grounded’ in the results.

The constant comparative method was developed by Glaser and Strauss, described in their book, Awareness of Dying (1965). They are seen as the founders of classic grounded theory.

Research teams use grounded theory to analyze social processes and relationships.

Because of the important role of data, there are key stages like data collection and data analysis that need to happen in order for the resulting data to be useful.

The grounded research results are compared to strengthen the validity of the findings to arrive at stronger defined theories. Once the data analysis cannot continue to refine the new theories down, a final theory is confirmed.

Grounded research is different from experimental research or scientific inquiry as it does not need a hypothesis theory at the start to verify. Instead, the evolving theory is based on facts and evidence discovered during each stage.Also, grounded research also doesn’t have a preconceived understanding of events or happenings before the qualitative research commences.

Free eBook: Qualitative research design handbook

When should you use grounded theory research?

Grounded theory research is useful for businesses when a researcher wants to look into a topic that has existing theory or no current research available. This means that the qualitative research results will be unique and can open the doors to the social phenomena being investigated.

In addition, businesses can use this qualitative research as the primary evidence needed to understand whether it’s worth placing investment into a new line of product or services, if the research identifies key themes and concepts that point to a solvable commercial problem.

Grounded theory methodology

There are several stages in the grounded theory process:

1. Data planning

The researcher decides what area they’re interested in.

They may create a guide to what they will be collecting during the grounded theory methodology. They will refer to this guide when they want to check the suitability of the qualitative data, as they collect it, to avoid preconceived ideas of what they know impacting the research.

A researcher can set up a grounded theory coding framework to identify the correct data. Coding is associating words, or labels, that are useful to the social phenomena that is being investigated. So, when the researcher sees these words, they assign the data to that category or theme.

In this stage, you’ll also want to create your open-ended initial research questions. Here are the main differences between open and closed-ended questions:

These will need to be adapted as the research goes on and more tangents and areas to explore are discovered. To help you create your questions, ask yourself:

• What are you trying to explain?
• What experiences do you need to ask about?
• Who will you ask and why?

2. Data collection and analysis

Data analysis happens at the same time as data collection. In grounded theory analysis, this is also known as constant comparative analysis, or theoretical sampling.

The researcher collects qualitative data by asking open-ended questions in interviews and surveys, studying historical or archival data, or observing participants and interpreting what is seen. This collected data is transferred into transcripts.

The categories or themes are compared and further refined by data, until there are only a few strong categories or themes remaining. Here is where coding occurs, and there are different levels of coding as the categories or themes are refined down:

• Data collection (Initial coding stage): Read through the data line by line
• Open coding stage: Read through the transcript data several times, breaking down the qualitative research data into excerpts, and make summaries of the concept or theme.
• Axial coding stage: Read through and compare further data collection to summarize concepts or themes to look for similarities and differences. Make defined summaries that help shape an emerging theory.
• Selective coding stage: Use the defined summaries to identify a strong core concept or theme.

During analysis, the researcher will apply theoretical sensitivity to the collected data they uncover, so that the meaning of nuances in what they see can be fully understood.

This coding process repeats until the researcher has reached theoretical saturation. In grounded theory analysis, this is where all data has been researched and there are no more possible categories or themes to explore.

3. Data analysis is turned into a final theory

The researcher takes the core categories and themes that they have gathered and integrates them into one central idea (a new theory) using selective code. This final grounded theory concludes the research.

The new theory should be a few simple sentences that describe the research, indicating what was and was not covered in it.

An example of using grounded theory in business

One example of how grounded theory may be used in business is to support HR teams by analyzing data to explore reasons why people leave a company.

For example, a company with a high attrition rate that has not done any research on this area before may choose grounded theory to understand key reasons why people choose to leave.

Researchers may start looking at the quantitative data around departures over the year and look for patterns. Coupled with this, they may conduct qualitative data research through employee engagement surveys , interview panels for current employees, and exit interviews with leaving employees.

From this information, they may start coding transcripts to find similarities and differences (coding) picking up on general themes and concepts. For example, a group of excepts like:

• “The hours I worked were far too long and I hated traveling home in the dark”
• “My manager didn’t appreciate the work I was doing, especially when I worked late”
• There are no good night bus routes home that I could take safely”

Using open coding, a researcher could compare excerpts and suggest the themes of managerial issues, a culture of long hours and lack of traveling routes at night.

With more samples and information, through axial coding, stronger themes of lack of recognition and having too much work (which led people to working late), could be drawn out from the summaries of the concepts and themes.

This could lead to a selective coding conclusion that people left because they were ‘overworked and under-appreciated’.

With this information, a grounded theory can help HR teams look at what teams do day to day, exploring ways to spread workloads or reduce them. Also, there could be training supplied to management and employees to engage professional development conversations better.

 Advantages of grounded theory

• No need for hypothesis – Researchers don’t need to know the details about the topic they want to investigate in advance, as the grounded theory methodology will bring up the information.
• Lots of flexibility – Researchers can take the topic in whichever direction they think is best, based on what the data is telling them. This means that exploration avenues that may be off-limits in traditional experimental research can be included.
• Multiple stages improve conclusion – Having a series of coding stages that refine the data into clear and strong concepts or themes means that the grounded theory will be more useful, relevant and defined.
• Data-first – Grounded theory relies on data analysis in the first instance, so the conclusion is based on information that has strong data behind it. This could be seen as having more validity.

Disadvantages of grounded theory

• Theoretical sensitivity dulled – If a researcher does not know enough about the topic being investigated, then their theoretical sensitivity about what data means may be lower and information may be missed if it is not coded properly.
• Large topics take time – There is a significant time resource required by the researcher to properly conduct research, evaluate the results and compare and analyze each excerpt. If the research process finds more avenues for investigation, for example, when excerpts contradict each other, then the researcher is required to spend more time doing qualitative inquiry.
• Bias in interpreting qualitative data – As the researcher is responsible for interpreting the qualitative data results, and putting their own observations into text, there can be researcher bias that would skew the data and possibly impact the final grounded theory.
• Qualitative research is harder to analyze than quantitative data – unlike numerical factual data from quantitative sources, qualitative data is harder to analyze as researchers will need to look at the words used, the sentiment and what is being said.
• Not repeatable – while the grounded theory can present a fact-based hypothesis, the actual data analysis from the research process cannot be repeated easily as opinions, beliefs and people may change over time. This may impact the validity of the grounded theory result.

What tools will help with grounded theory?

Evaluating qualitative research can be tough when there are several analytics platforms to manage and lots of subjective data sources to compare. Some tools are already part of the office toolset, like video conferencing tools and excel spreadsheets.

However, most tools are not purpose-built for research, so researchers will be manually collecting and managing these files – in the worst case scenario, by pen and paper!

Use a best-in-breed management technology solution to collect all qualitative research and manage it in an organized way without large time resources or additional training required.

Qualtrics provides a number of qualitative research analysis tools, like Text iQ , powered by Qualtrics iQ, provides powerful machine learning and native language processing to help you discover patterns and trends in text.

This also provides you with research process tools:

• Sentiment analysis — a technique to help identify the underlying sentiment (say positive, neutral, and/or negative) in qualitative research text responses
• Topic detection/categorisation — The solution makes it easy to add new qualitative research codes and group by theme. Easily group or bucket of similar themes that can be relevant for the business and the industry (eg. ‘Food quality’, ‘Staff efficiency’ or ‘Product availability’)

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Market intelligence 10 min read, marketing insights 11 min read, ethnographic research 11 min read, qualitative vs quantitative research 13 min read, qualitative research questions 11 min read, qualitative research design 12 min read, primary vs secondary research 14 min read, request demo.

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Grounded Theory Methodology: Key Principles

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• Walter J. Eppich 6 ,
• Francisco M. Olmos-Vega 7 , 8 &
• Christopher J. Watling 9  

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Grounded theory (GT) is a common qualitative methodology in health professions education research used to explore the “how”, “what”, and “why” of social processes. With GT researchers aim to understand how study participants interpret reality related to the process in question. However, they risk misapplying the term to studies that do not actually use GT methodology. We outline key features that characterize GT research, namely iterative data collection and analysis, constant comparison, and theoretical sampling. Constructivist GT is a particular form of GT that explicitly recognizes the researcher’s role in knowledge creation throughout the analytic process. Data may be collected through interviews, field observations, video analysis, document review, or a combination of these methods. The analytic process involves several flexible coding phases that move from concrete initial coding to higher level focused codes and finally to axial coding with the goal of a conceptual understanding that is situated in the study context.

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Francisco M. Olmos-Vega

Anesthesiology Department, Hospital Universitario San Ignacio, Bogotá, Colombia

Departments of Clinical Neurological Sciences and Oncology, Office of Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

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Eppich, W.J., Olmos-Vega, F.M., Watling, C.J. (2019). Grounded Theory Methodology: Key Principles. In: Nestel, D., Hui, J., Kunkler, K., Scerbo, M., Calhoun, A. (eds) Healthcare Simulation Research. Springer, Cham. https://doi.org/10.1007/978-3-030-26837-4_18

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Developing theory with the grounded-theory approach and thematic analysis.

• Experimental Psychology
• Statistical Analysis
• Stereotypes

Grounded theory is an approach by which theory is extended from qualitative analysis (Charmaz, 1990; Walsh, 2014). It began nearly 5 decades ago (Glaser & Straus, 1967) and has since developed and diversified (Heath & Cowley, 2004). This article outlines a process of thematic analysis directed by the grounded-theory approach and discusses the conditions under which this process is most suitable, using examples from my work with a research team on my master’s thesis about gender-role conceptions among Latinas (Heydarian, 2016).

The use of thematic analysis driven by grounded theory is particularly informative for this area of cultural research. The prominent literature of Latina gender studies in the social sciences promotes a stereotypical image of Latinas as submissive and dependent; the grounded-theory approach to thematic analysis allowed me to explore the detail and nuances of how Latina women themselves describe the Latina experience. From my own analyses, I found that Latinas view the experience of being a woman in Latina culture as a complex identity beyond stereotypes. The study participants noted that their identity changes and evolves in different situations and across the lifespan. These findings have implications for how Latinas are viewed and treated in social-science research, setting the stage for future directions in sociocultural and clinical studies.

Grounded Theory in Data Collection

Grounded theory is an approach whereby the researcher refers back to the literature relevant to the research topic and to qualitative observations throughout data collection and analysis. Review of the literature and qualitative data can help shape subsequent data collection and analysis according to new perspectives that arise from reference to previous research and participants’ observations. During the data-collection stage, the researcher may realize previously unanticipated characteristics of the construct by analyzing participants’ responses and consequently refine subsequent data collection.

Grounded Theory in Thematic Analysis

The grounded-theory approach also may be applied to the data-analysis stage of a study. This process involves the critical review of responses to determine appropriate coding and the formation of themes from those codes. Researchers can conduct thematic analyses on the transcriptions of participants’ responses to interview questions, other dialogue, or responses to open-ended questions (Braun & Clarke, 2006; Pope & Mays, 1995). I examined responses to the question “What it is like to be ‘feminine’ and ‘motherly?’” from a semistructured interview.

Preparing and Revising the Codebook

The researcher first develops a preliminary codebook — a predetermined set of constructs and their associated definitions and characteristics. (This codebook will be refined throughout analysis.) This is determined a priori from the existing literature, the proposed research questions, and consultations with experts familiar with the constructs of interest. For example, one construct that emerged in my study of Latinas’ perspectives of gender roles was familismo — prioritizing, providing for, and taking care of the family (Castillo, Perez, Castillo, & Ghosheh, 2010; Guzmán, 2011; Heydarian, 2016; Lugo-Steidel & Contreras, 2003). Codes initially assigned to one theme may be moved to another theme during later stages of the analysis.

The researcher then will need to select certain themes to report. This selection is based on what the researcher determines to be the smallest-sized theme of interest for answering the research question (i.e., what is the smallest number of people who gave a response that fits within that theme?) and the practices of the field. The researcher also may choose to highlight themes of particular theoretical interest.

During this final stage of coding, subthemes may be identified. These may emerge when several participants give similar detailed descriptions of a characteristic of the theme. For example, a subtheme of the theme familismo may include taking care of children (Heydarian, 2016).

The Coding Process

The coding process entails reading through the data and list of response codes, referring back to the original interview transcriptions, and reassigning response codes to different themes that best represent them. Ideally, the researcher should analyze the data with a team of two or more research assistants familiar with the codebook and coding procedures.

After response codes are identified, researchers can sort them into themes. Both theory-driven (deductive) and data-driven (inductive) stages of analysis can be used to generate themes from the response codes. The researcher and research assistants independently examine the response-code data for theory-driven themes according to the codebook, then meet to resolve coding discrepancies and identify quotes that did not fit within the theory-driven themes. Then the members of the research team independently can examine the response codes that did not fit within the predetermined deductive themes and identify new, inductively derived themes. It is important for the raters to carry out this stage independently so that their interpretations of the data are not influenced by others. The team constructs new themes that are not described by previous literature, with corresponding definitions to capture the prevalent characteristics described by the participants. For example, one previously unidentified construct associated with marianismo — the constellation of stereotypes associated with women in Latina culture — is empowerment (Heydarian, 2016). Our research team identified an internal empowerment theme and an external empowerment theme. Internal empowerment refers to the sense of a strong identity and self-confidence; external empowerment refers to the desire and self-efficacy to make a positive change in one’s own life and in the community.

The research team will meet again following the second stage of independent coding to consult on the quotes that were not assigned to either the deductive theme or the inductive theme. After the discussion of possible inductive themes, the primary researcher reviews all of the coding and arrives upon a final codebook.

Limitations and Strengths

The grounded-theory approach to qualitative data analysis is heavily directed by the primary researcher. This element of the approach can introduce bias into the analysis. The primary researcher must carefully consider the perspectives of the research-team members and the research participants by revisiting the data several times when revising the codebook. The research team that I worked with for the study on gender-role perspectives of Latinas contributed greatly to shaping the codebook and findings of the study, and ultimately helped contribute to the field.

The grounded-theory approach is useful when the area of study is new. It also is helpful for identifying details of constructs. In addition to themes and subthemes related to familismo and empowerment, we discovered themes capturing perspectives about beauty, interpersonal manners, and human qualities (e.g., being loving and caring). When the researcher carefully considers other perspectives and is well versed in the existing literature related to the research topic, the analysis can make a great contribution to shaping theory. œ

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 , 77–101.

Castillo, L. G., Perez, F. V., Castillo, R., & Ghosheh, M. R. (2010). Construction and initial validation of the Marianismo Beliefs Scale. Counseling Psychology Quarterly, 23 , 163–175. doi:10.1080/09515071003776036

Charmaz, K. (1990). ‘Discovering’ chronic illness: Using grounded theory. Social Science Medicine , 30 , 1161–1172.

Glaser, B., & Strauss, A. (1967). The discovery of grounded theory . Hawthorne, NY: Aldine Publishing Company.

Guzmán, C. E. (2011). Toward a new conceptualization of marianismo : Validation of the Guzm á n Marianismo Inventory (Unpublished doctoral dissertation). Retrieved from ProQuest. (3534136)

Heydarian, N. M. (2016). Perspectives of feminine cultural gender role values from Latina leaders and community residents (Unpublished master’s thesis). Retrieved from ProQuest.

Heath, H., & Cowley, S. (2004). Developing a grounded theory approach: A comparison of Glasser and Strauss. International Journal of Nursing Studies , 41 , 141–150.

Lugo-Steidel, A. G., & Contreras, J. M. (2003). A new familism scale for use with Latino populations. Hispanic Journal of Behavioral Sciences , 25 , 312–330.

Pope, C., & Mays, N. (1995). Reaching the parts other methods cannot reach: An introduction to qualitative methods in health and health services research. Journal of Behavioral Medicine, 311 , 42–45.

Walsh, I. (2014). Using grounded theory to avoid research misconduct in management science. Grounded Theory Review , 13 . Retrieved from http://groundedtheoryreview.com/2014/06/22/using-grounded-theory-to-avoid-research misconduct-in-management-science/

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About the Author

Nazanin Mina Heydarian is a doctoral candidate in the University of Texas at El Paso’s Health Psychology program. Her research interests include medical decision-making and prejudice as well as attitudes and attributions about people with disabilities and chronic medical conditions.

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How to do a grounded theory study: a worked example of a study of dental practices

Alexandra sbaraini.

1 Centre for Values, Ethics and the Law in Medicine, University of Sydney, Sydney, New South Wales, Australia

2 Population Oral Health, Faculty of Dentistry, University of Sydney, Sydney, New South Wales, Australia

Stacy M Carter

R wendell evans, anthony blinkhorn, associated data.

Qualitative methodologies are increasingly popular in medical research. Grounded theory is the methodology most-often cited by authors of qualitative studies in medicine, but it has been suggested that many 'grounded theory' studies are not concordant with the methodology. In this paper we provide a worked example of a grounded theory project. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

We documented a worked example of using grounded theory methodology in practice.

We describe our sampling, data collection, data analysis and interpretation. We explain how these steps were consistent with grounded theory methodology, and show how they related to one another. Grounded theory methodology assisted us to develop a detailed model of the process of adapting preventive protocols into dental practice, and to analyse variation in this process in different dental practices.

Conclusions

By employing grounded theory methodology rigorously, medical researchers can better design and justify their methods, and produce high-quality findings that will be more useful to patients, professionals and the research community.

Qualitative research is increasingly popular in health and medicine. In recent decades, qualitative researchers in health and medicine have founded specialist journals, such as Qualitative Health Research , established 1991, and specialist conferences such as the Qualitative Health Research conference of the International Institute for Qualitative Methodology, established 1994, and the Global Congress for Qualitative Health Research, established 2011 [ 1 - 3 ]. Journals such as the British Medical Journal have published series about qualitative methodology (1995 and 2008) [ 4 , 5 ]. Bodies overseeing human research ethics, such as the Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, and the Australian National Statement on Ethical Conduct in Human Research [ 6 , 7 ], have included chapters or sections on the ethics of qualitative research. The increasing popularity of qualitative methodologies for medical research has led to an increasing awareness of formal qualitative methodologies. This is particularly so for grounded theory, one of the most-cited qualitative methodologies in medical research [[ 8 ], p47].

Grounded theory has a chequered history [ 9 ]. Many authors label their work 'grounded theory' but do not follow the basics of the methodology [ 10 , 11 ]. This may be in part because there are few practical examples of grounded theory in use in the literature. To address this problem, we will provide a brief outline of the history and diversity of grounded theory methodology, and a worked example of the methodology in practice. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.

The history, diversity and basic components of 'grounded theory' methodology and method

Founded on the seminal 1967 book 'The Discovery of Grounded Theory' [ 12 ], the grounded theory tradition is now diverse and somewhat fractured, existing in four main types, with a fifth emerging. Types one and two are the work of the original authors: Barney Glaser's 'Classic Grounded Theory' [ 13 ] and Anselm Strauss and Juliet Corbin's 'Basics of Qualitative Research' [ 14 ]. Types three and four are Kathy Charmaz's 'Constructivist Grounded Theory' [ 15 ] and Adele Clarke's postmodern Situational Analysis [ 16 ]: Charmaz and Clarke were both students of Anselm Strauss. The fifth, emerging variant is 'Dimensional Analysis' [ 17 ] which is being developed from the work of Leonard Schaztman, who was a colleague of Strauss and Glaser in the 1960s and 1970s.

There has been some discussion in the literature about what characteristics a grounded theory study must have to be legitimately referred to as 'grounded theory' [ 18 ]. The fundamental components of a grounded theory study are set out in Table ​ Table1. 1 . These components may appear in different combinations in other qualitative studies; a grounded theory study should have all of these. As noted, there are few examples of 'how to do' grounded theory in the literature [ 18 , 19 ]. Those that do exist have focused on Strauss and Corbin's methods [ 20 - 25 ]. An exception is Charmaz's own description of her study of chronic illness [ 26 ]; we applied this same variant in our study. In the remainder of this paper, we will show how each of the characteristics of grounded theory methodology worked in our study of dental practices.

Fundamental components of a grounded theory study

Study background

We used grounded theory methodology to investigate social processes in private dental practices in New South Wales (NSW), Australia. This grounded theory study builds on a previous Australian Randomized Controlled Trial (RCT) called the Monitor Dental Practice Program (MPP) [ 27 ]. We know that preventive techniques can arrest early tooth decay and thus reduce the need for fillings [ 28 - 32 ]. Unfortunately, most dentists worldwide who encounter early tooth decay continue to drill it out and fill the tooth [ 33 - 37 ]. The MPP tested whether dentists could increase their use of preventive techniques. In the intervention arm, dentists were provided with a set of evidence-based preventive protocols to apply [ 38 ]; control practices provided usual care. The MPP protocols used in the RCT guided dentists to systematically apply preventive techniques to prevent new tooth decay and to arrest early stages of tooth decay in their patients, therefore reducing the need for drilling and filling. The protocols focused on (1) primary prevention of new tooth decay (tooth brushing with high concentration fluoride toothpaste and dietary advice) and (2) intensive secondary prevention through professional treatment to arrest tooth decay progress (application of fluoride varnish, supervised monitoring of dental plaque control and clinical outcomes)[ 38 ].

As the RCT unfolded, it was discovered that practices in the intervention arm were not implementing the preventive protocols uniformly. Why had the outcomes of these systematically implemented protocols been so different? This question was the starting point for our grounded theory study. We aimed to understand how the protocols had been implemented, including the conditions and consequences of variation in the process. We hoped that such understanding would help us to see how the norms of Australian private dental practice as regards to tooth decay could be moved away from drilling and filling and towards evidence-based preventive care.

Designing this grounded theory study

Figure ​ Figure1 1 illustrates the steps taken during the project that will be described below from points A to F.

Study design . file containing a figure illustrating the study design.

A. An open beginning and research questions

Grounded theory studies are generally focused on social processes or actions: they ask about what happens and how people interact . This shows the influence of symbolic interactionism, a social psychological approach focused on the meaning of human actions [ 39 ]. Grounded theory studies begin with open questions, and researchers presume that they may know little about the meanings that drive the actions of their participants. Accordingly, we sought to learn from participants how the MPP process worked and how they made sense of it. We wanted to answer a practical social problem: how do dentists persist in drilling and filling early stages of tooth decay, when they could be applying preventive care?

We asked research questions that were open, and focused on social processes. Our initial research questions were:

• What was the process of implementing (or not-implementing) the protocols (from the perspective of dentists, practice staff, and patients)?

• How did this process vary?

B. Ethics approval and ethical issues

In our experience, medical researchers are often concerned about the ethics oversight process for such a flexible, unpredictable study design. We managed this process as follows. Initial ethics approval was obtained from the Human Research Ethics Committee at the University of Sydney. In our application, we explained grounded theory procedures, in particular the fact that they evolve. In our initial application we provided a long list of possible recruitment strategies and interview questions, as suggested by Charmaz [ 15 ]. We indicated that we would make future applications to modify our protocols. We did this as the study progressed - detailed below. Each time we reminded the committee that our study design was intended to evolve with ongoing modifications. Each modification was approved without difficulty. As in any ethical study, we ensured that participation was voluntary, that participants could withdraw at any time, and that confidentiality was protected. All responses were anonymised before analysis, and we took particular care not to reveal potentially identifying details of places, practices or clinicians.

C. Initial, Purposive Sampling (before theoretical sampling was possible)

Grounded theory studies are characterised by theoretical sampling, but this requires some data to be collected and analysed. Sampling must thus begin purposively, as in any qualitative study. Participants in the previous MPP study provided our population [ 27 ]. The MPP included 22 private dental practices in NSW, randomly allocated to either the intervention or control group. With permission of the ethics committee; we sent letters to the participants in the MPP, inviting them to participate in a further qualitative study. From those who agreed, we used the quantitative data from the MPP to select an initial sample.

Then, we selected the practice in which the most dramatic results had been achieved in the MPP study (Dental Practice 1). This was a purposive sampling strategy, to give us the best possible access to the process of successfully implementing the protocols. We interviewed all consenting staff who had been involved in the MPP (one dentist, five dental assistants). We then recruited 12 patients who had been enrolled in the MPP, based on their clinically measured risk of developing tooth decay: we selected some patients whose risk status had gotten better, some whose risk had worsened and some whose risk had stayed the same. This purposive sample was designed to provide maximum variation in patients' adoption of preventive dental care.

Initial Interviews

One hour in-depth interviews were conducted. The researcher/interviewer (AS) travelled to a rural town in NSW where interviews took place. The initial 18 participants (one dentist, five dental assistants and 12 patients) from Dental Practice 1 were interviewed in places convenient to them such as the dental practice, community centres or the participant's home.

Two initial interview schedules were designed for each group of participants: 1) dentists and dental practice staff and 2) dental patients. Interviews were semi-structured and based loosely on the research questions. The initial questions for dentists and practice staff are in Additional file 1 . Interviews were digitally recorded and professionally transcribed. The research location was remote from the researcher's office, thus data collection was divided into two episodes to allow for intermittent data analysis. Dentist and practice staff interviews were done in one week. The researcher wrote memos throughout this week. The researcher then took a month for data analysis in which coding and memo-writing occurred. Then during a return visit, patient interviews were completed, again with memo-writing during the data-collection period.

D. Data Analysis

Coding and the constant comparative method.

Coding is essential to the development of a grounded theory [ 15 ]. According to Charmaz [[ 15 ], p46], 'coding is the pivotal link between collecting data and developing an emergent theory to explain these data. Through coding, you define what is happening in the data and begin to grapple with what it means'. Coding occurs in stages. In initial coding, the researcher generates as many ideas as possible inductively from early data. In focused coding, the researcher pursues a selected set of central codes throughout the entire dataset and the study. This requires decisions about which initial codes are most prevalent or important, and which contribute most to the analysis. In theoretical coding, the researcher refines the final categories in their theory and relates them to one another. Charmaz's method, like Glaser's method [ 13 ], captures actions or processes by using gerunds as codes (verbs ending in 'ing'); Charmaz also emphasises coding quickly, and keeping the codes as similar to the data as possible.

We developed our coding systems individually and through team meetings and discussions.

We have provided a worked example of coding in Table ​ Table2. 2 . Gerunds emphasise actions and processes. Initial coding identifies many different processes. After the first few interviews, we had a large amount of data and many initial codes. This included a group of codes that captured how dentists sought out evidence when they were exposed to a complex clinical case, a new product or technique. Because this process seemed central to their practice, and because it was talked about often, we decided that seeking out evidence should become a focused code. By comparing codes against codes and data against data, we distinguished the category of "seeking out evidence" from other focused codes, such as "gathering and comparing peers' evidence to reach a conclusion", and we understood the relationships between them. Using this constant comparative method (see Table ​ Table1), 1 ), we produced a theoretical code: "making sense of evidence and constructing knowledge". This code captured the social process that dentists went through when faced with new information or a practice challenge. This theoretical code will be the focus of a future paper.

Coding process

Memo-writing

Throughout the study, we wrote extensive case-based memos and conceptual memos. After each interview, the interviewer/researcher (AS) wrote a case-based memo reflecting on what she learned from that interview. They contained the interviewer's impressions about the participants' experiences, and the interviewer's reactions; they were also used to systematically question some of our pre-existing ideas in relation to what had been said in the interview. Table ​ Table3 3 illustrates one of those memos. After a few interviews, the interviewer/researcher also began making and recording comparisons among these memos.

Case-based memo

We also wrote conceptual memos about the initial codes and focused codes being developed, as described by Charmaz [ 15 ]. We used these memos to record our thinking about the meaning of codes and to record our thinking about how and when processes occurred, how they changed, and what their consequences were. In these memos, we made comparisons between data, cases and codes in order to find similarities and differences, and raised questions to be answered in continuing interviews. Table ​ Table4 4 illustrates a conceptual memo.

Conceptual memo

At the end of our data collection and analysis from Dental Practice 1, we had developed a tentative model of the process of implementing the protocols, from the perspective of dentists, dental practice staff and patients. This was expressed in both diagrams and memos, was built around a core set of focused codes, and illustrated relationships between them.

E. Theoretical sampling, ongoing data analysis and alteration of interview route

We have already described our initial purposive sampling. After our initial data collection and analysis, we used theoretical sampling (see Table ​ Table1) 1 ) to determine who to sample next and what questions to ask during interviews. We submitted Ethics Modification applications for changes in our question routes, and had no difficulty with approval. We will describe how the interview questions for dentists and dental practice staff evolved, and how we selected new participants to allow development of our substantive theory. The patients' interview schedule and theoretical sampling followed similar procedures.

Evolution of theoretical sampling and interview questions

We now had a detailed provisional model of the successful process implemented in Dental Practice 1. Important core focused codes were identified, including practical/financial, historical and philosophical dimensions of the process. However, we did not yet understand how the process might vary or go wrong, as implementation in the first practice we studied had been described as seamless and beneficial for everyone. Because our aim was to understand the process of implementing the protocols, including the conditions and consequences of variation in the process, we needed to understand how implementation might fail. For this reason, we theoretically sampled participants from Dental Practice 2, where uptake of the MPP protocols had been very limited according to data from the RCT trial.

We also changed our interview questions based on the analysis we had already done (see Additional file 2 ). In our analysis of data from Dental Practice 1, we had learned that "effectiveness" of treatments and "evidence" both had a range of meanings. We also learned that new technologies - in particular digital x-rays and intra-oral cameras - had been unexpectedly important to the process of implementing the protocols. For this reason, we added new questions for the interviews in Dental Practice 2 to directly investigate "effectiveness", "evidence" and how dentists took up new technologies in their practice.

Then, in Dental Practice 2 we learned more about the barriers dentists and practice staff encountered during the process of implementing the MPP protocols. We confirmed and enriched our understanding of dentists' processes for adopting technology and producing knowledge, dealing with complex cases and we further clarified the concept of evidence. However there was a new, important, unexpected finding in Dental Practice 2. Dentists talked about "unreliable" patients - that is, patients who were too unreliable to have preventive dental care offered to them. This seemed to be a potentially important explanation for non-implementation of the protocols. We modified our interview schedule again to include questions about this concept (see Additional file 3 ) leading to another round of ethics approvals. We also returned to Practice 1 to ask participants about the idea of an "unreliable" patient.

Dentists' construction of the "unreliable" patient during interviews also prompted us to theoretically sample for "unreliable" and "reliable" patients in the following round of patients' interviews. The patient question route was also modified by the analysis of the dentists' and practice staff data. We wanted to compare dentists' perspectives with the perspectives of the patients themselves. Dentists were asked to select "reliable" and "unreliable" patients to be interviewed. Patients were asked questions about what kind of services dentists should provide and what patients valued when coming to the dentist. We found that these patients (10 reliable and 7 unreliable) talked in very similar ways about dental care. This finding suggested to us that some deeply-held assumptions within the dental profession may not be shared by dental patients.

At this point, we decided to theoretically sample dental practices from the non-intervention arm of the MPP study. This is an example of the 'openness' of a grounded theory study potentially subtly shifting the focus of the study. Our analysis had shifted our focus: rather than simply studying the process of implementing the evidence-based preventive protocols, we were studying the process of doing prevention in private dental practice. All participants seemed to be revealing deeply held perspectives shared in the dental profession, whether or not they were providing dental care as outlined in the MPP protocols. So, by sampling dentists from both intervention and control group from the previous MPP study, we aimed to confirm or disconfirm the broader reach of our emerging theory and to complete inductive development of key concepts. Theoretical sampling added 12 face to face interviews and 10 telephone interviews to the data. A total of 40 participants between the ages of 18 and 65 were recruited. Telephone interviews were of comparable length, content and quality to face to face interviews, as reported elsewhere in the literature [ 40 ].

F. Mapping concepts, theoretical memo writing and further refining of concepts

After theoretical sampling, we could begin coding theoretically. We fleshed out each major focused code, examining the situations in which they appeared, when they changed and the relationship among them. At time of writing, we have reached theoretical saturation (see Table ​ Table1). 1 ). We have been able to determine this in several ways. As we have become increasingly certain about our central focused codes, we have re-examined the data to find all available insights regarding those codes. We have drawn diagrams and written memos. We have looked rigorously for events or accounts not explained by the emerging theory so as to develop it further to explain all of the data. Our theory, which is expressed as a set of concepts that are related to one another in a cohesive way, now accounts adequately for all the data we have collected. We have presented the developing theory to specialist dental audiences and to the participants, and have found that it was accepted by and resonated with these audiences.

We have used these procedures to construct a detailed, multi-faceted model of the process of incorporating prevention into private general dental practice. This model includes relationships among concepts, consequences of the process, and variations in the process. A concrete example of one of our final key concepts is the process of "adapting to" prevention. More commonly in the literature writers speak of adopting, implementing or translating evidence-based preventive protocols into practice. Through our analysis, we concluded that what was required was 'adapting to' those protocols in practice. Some dental practices underwent a slow process of adapting evidence-based guidance to their existing practice logistics. Successful adaptation was contingent upon whether (1) the dentist-in-charge brought the whole dental team together - including other dentists - and got everyone interested and actively participating during preventive activities; (2) whether the physical environment of the practice was re-organised around preventive activities, (3) whether the dental team was able to devise new and efficient routines to accommodate preventive activities, and (4) whether the fee schedule was amended to cover the delivery of preventive services, which hitherto was considered as "unproductive time".

Adaptation occurred over time and involved practical, historical and philosophical aspects of dental care. Participants transitioned from their initial state - selling restorative care - through an intermediary stage - learning by doing and educating patients about the importance of preventive care - and finally to a stage where they were offering patients more than just restorative care. These are examples of ways in which participants did not simply adopt protocols in a simple way, but needed to adapt the protocols and their own routines as they moved toward more preventive practice.

The quality of this grounded theory study

There are a number of important assurances of quality in keeping with grounded theory procedures and general principles of qualitative research. The following points describe what was crucial for this study to achieve quality.

During data collection

1. All interviews were digitally recorded, professionally transcribed in detail and the transcripts checked against the recordings.

2. We analysed the interview transcripts as soon as possible after each round of interviews in each dental practice sampled as shown on Figure ​ Figure1. 1 . This allowed the process of theoretical sampling to occur.

3. Writing case-based memos right after each interview while being in the field allowed the researcher/interviewer to capture initial ideas and make comparisons between participants' accounts. These memos assisted the researcher to make comparison among her reflections, which enriched data analysis and guided further data collection.

4. Having the opportunity to contact participants after interviews to clarify concepts and to interview some participants more than once contributed to the refinement of theoretical concepts, thus forming part of theoretical sampling.

5. The decision to include phone interviews due to participants' preference worked very well in this study. Phone interviews had similar length and depth compared to the face to face interviews, but allowed for a greater range of participation.

During data analysis

1. Detailed analysis records were kept; which made it possible to write this explanatory paper.

2. The use of the constant comparative method enabled the analysis to produce not just a description but a model, in which more abstract concepts were related and a social process was explained.

3. All researchers supported analysis activities; a regular meeting of the research team was convened to discuss and contextualize emerging interpretations, introducing a wide range of disciplinary perspectives.

Answering our research questions

We developed a detailed model of the process of adapting preventive protocols into dental practice, and analysed the variation in this process in different dental practices. Transferring evidence-based preventive protocols into these dental practices entailed a slow process of adapting the evidence to the existing practices logistics. Important practical, philosophical and historical elements as well as barriers and facilitators were present during a complex adaptation process. Time was needed to allow dentists and practice staff to go through this process of slowly adapting their practices to this new way of working. Patients also needed time to incorporate home care activities and more frequent visits to dentists into their daily routines. Despite being able to adapt or not, all dentists trusted the concrete clinical evidence that they have produced, that is, seeing results in their patients mouths made them believe in a specific treatment approach.

Concluding remarks

This paper provides a detailed explanation of how a study evolved using grounded theory methodology (GTM), one of the most commonly used methodologies in qualitative health and medical research [[ 8 ], p47]. In 2007, Bryant and Charmaz argued:

'Use of GTM, at least as much as any other research method, only develops with experience. Hence the failure of all those attempts to provide clear, mechanistic rules for GTM: there is no 'GTM for dummies'. GTM is based around heuristics and guidelines rather than rules and prescriptions. Moreover, researchers need to be familiar with GTM, in all its major forms, in order to be able to understand how they might adapt it in use or revise it into new forms and variations.' [[ 8 ], p17].

Our detailed explanation of our experience in this grounded theory study is intended to provide, vicariously, the kind of 'experience' that might help other qualitative researchers in medicine and health to apply and benefit from grounded theory methodology in their studies. We hope that our explanation will assist others to avoid using grounded theory as an 'approving bumper sticker' [ 10 ], and instead use it as a resource that can greatly improve the quality and outcome of a qualitative study.

Abbreviations

GTM: grounded theory methods; MPP: Monitor Dental Practice Program; NSW: New South Wales; RCT: Randomized Controlled Trial.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

All authors have made substantial contributions to conception and design of this study. AS carried out data collection, analysis, and interpretation of data. SMC made substantial contribution during data collection, analysis and data interpretation. AS, SMC, RWE, and AB have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2288/11/128/prepub

Supplementary Material

Initial interview schedule for dentists and dental practice staff . file containing initial interview schedule for dentists and dental practice staff.

Questions added to the initial interview schedule for dentists and dental practice staff . file containing questions added to the initial interview schedule

Questions added to the modified interview schedule for dentists and dental practice staff . file containing questions added to the modified interview schedule

Acknowledgements

We thank dentists, dental practice staff and patients for their invaluable contributions to the study. We thank Emeritus Professor Miles Little for his time and wise comments during the project.

The authors received financial support for the research from the following funding agencies: University of Sydney Postgraduate Award 2009; The Oral Health Foundation, University of Sydney; Dental Board New South Wales; Australian Dental Research Foundation; National Health and Medical Research Council Project Grant 632715.

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ORIGINAL RESEARCH article

No change a grounded theory analysis of depressed patients' perspectives on non-improvement in psychotherapy.

• 1 Department of Psychoanalysis and Clinical Consulting, Ghent University, Ghent, Belgium
• 2 Fonds Wetenschappelijk Onderzoek, Brussels, Belgium

Aim: Understanding the effects of psychotherapy is a crucial concern for both research and clinical practice, especially when outcome tends to be negative. Yet, while outcome is predominantly evaluated by means of quantitative pre-post outcome questionnaires, it remains unclear what this actually means for patients in their daily lives. To explore this meaning, it is imperative to combine treatment evaluation with quantitative and qualitative outcome measures. This study investigates the phenomenon of non-improvement in psychotherapy, by complementing quantitative pre-post outcome scores that indicate no reliable change in depression symptoms with a qualitative inquiry of patients' perspectives.

Methods: The study took place in the context of a Randomised Controlled Trial evaluating time-limited psychodynamic and cognitive behavioral therapy for major depression. A mixed methods study was conducted including patients' pre-post outcome scores on the BDI-II-NL and post treatment Client Change Interviews. Nineteen patients whose data showed no reliable change in depression symptoms were selected. A grounded theory analysis was conducted on the transcripts of patients' interviews.

Findings: From the patients' perspective, non-improvement can be understood as being stuck between knowing versus doing, resulting in a stalemate. Positive changes (mental stability, personal strength, and insight) were stimulated by therapy offering moments of self-reflection and guidance, the benevolent therapist approach and the context as important motivations. Remaining issues (ambition to change but inability to do so) were attributed to the therapy hitting its limits, patients' resistance and impossibility and the context as a source of distress. “No change” in outcome scores therefore seems to involve a “partial change” when considering the patients' perspectives.

Conclusion: The study shows the value of integrating qualitative first-person analyses into standard quantitative outcome evaluation and particularly for understanding the phenomenon of non-improvement. It argues for more multi-method and multi-perspective research to gain a better understanding of (negative) outcome and treatment effects. Implications for both research and practice are discussed.

Negative outcome or nonresponse to treatment is undeniably part of clinical practice. It is estimated that 5 to 10% of patients deteriorates in therapy ( Cooper, 2008 ; Lambert, 2013 ), and a proportion of 35 to 40% of the participants in clinical trials do not improve ( Lambert, 2007 ). A better understanding of negative outcome and treatment effects is crucial for both research and clinical practice, yet outcome research has focused predominantly on capturing positive change and “what works,” while less is known about non-improvement or what it actually means when treatments fail ( Barlow, 2010 ).

There is no uniform understanding of negative outcome, nor is there agreement on the definition of treatment failure ( Lambert, 2011 ; Lampropoulos, 2011 ). “Negative outcome” and “negative therapeutic effects” are often used as synonyms, although they do not have a one-on-one relationship, as negative outcome is not necessarily caused by therapy ( Mays and Franks, 1985 ; Mohr, 1995 ). Depending on the perspective (e.g., patient, therapist, researcher), the type of outcome (e.g., symptoms, quality of life), measurement method (e.g., quantitative or qualitative) and time point (e.g., post treatment or follow-up) being used for treatment evaluation, the conception of outcome and treatment effects varies ( Lampropoulos, 2011 ).

In outcome research, outcome and treatment effects are typically evaluated using statistical tests of significance that provide an indication of the reliability of the measured change. Statistical significance shows that an outcome difference is larger than could have been expected by mere chance. Clinical significance shows whether such a statistical effect is also clinically meaningful (i.e., change toward a normal level of functioning) ( Jacobson et al., 1999 ; Ogles et al., 2001 ; Lambert et al., 2008 ; Lambert and Ogles, 2009 ). Based on the Jacobson and Truax widely used method for clinical significance, outcome can be classified into four categories: (1) recovery (i.e., clinically significant change), (2) improvement (i.e., reliable change), (3) no reliable change and (4) deterioration (i.e., reliable change in the negative direction). Generally, the first category “recovery” is taken as the gold standard outcome and treatment goal: a reliable decrease in symptoms 1 and return to a non-clinical level of functioning. When neither criterion is met, it is concluded that patients remained “unchanged” in comparison to their level of functioning prior to treatment ( Jacobson and Truax, 1991 ).

Despite the added value of clinical significance testing of measured changes, this type of statistical outcome classification cannot overcome the limitations that are voices for standard outcome research ( Hill et al., 2013 ). Quantitative pre-post outcome evaluation is criticised for relying predominantly on one-dimensional rating scales, most often symptom-based ( Braakmann, 2015 ), and consequently, for offering only an incomplete approximation of the multi-dimensional nature of human functioning ( Kazdin, 2001 ; Hill et al., 2013 ). The possible discrepancy between what is measured with outcome questionnaires and what is meaningful in patients' daily life has been problematised: a patient's outcome score might fall within the non-clinical range while it does not reflect the person's functioning ( Kazdin, 2011 ). Real-life contextualisation is necessary in order to make sense of what changes in scores (or the lack thereof) actually mean for an individual ( Blanton and Jaccard, 2006 ; Kazdin, 2006 ). The latter is typically missing in large sample standardised outcome studies, and consequently, the dissemination of research findings into clinical practice generally fails ( Kazdin, 2008 ).

The past decades have seen an accumulation of qualitative studies attempting to contribute to overcoming this research-practice barrier, gradually offering a more central role to the voice of patients ( Levitt et al., 2016 ). Qualitative research focusing on patients' experiences of outcome has provided a diverse picture of treatment-related changes ( McLeod, 2011 ). Apart from symptomatic changes, alterations on the level of patients' self, life, interpersonal relations, and self-understanding have been observed (e.g., Binder et al., 2009 ). The largest strand of qualitative psychotherapy research has focused on patients' experiences of therapy, aiming to identify helping and hindering aspects ( McLeod, 2013 ). Hindering elements in therapy that have been mentioned by patients are contra-productive therapist features (e.g., being unsure, absent or non-responsive, lack of direction and advise in therapy), patients' own difficulties to express or get in touch with their feelings and lack of commitment and motivation, and a lack of trust between patient and therapist ( Paulson et al., 2001 ; von Below and Werbart, 2012 ) and so forth. On the other hand, a joint exploration of difficulties and experiencing warmth, understanding and empathy in the relationship with the therapist were found to be helpful for patients ( Timulak and Lietaer, 2001 ; Lilliengren and Werbart, 2005 ; Bohart and Wade, 2013 ).

Interestingly, findings from qualitative outcome studies shine a somewhat more pessimistic light on psychotherapy outcome than is typically observed in quantitative studies. In general, patients tend to be more critical about therapy during interviews, for instance, expressing disappointment about unaltered core problems or ambivalence about the gains of therapy ( McLeod, 2013 ). Moreover, research findings suggest that, patients' treatment satisfaction does not correspond to changes in outcome scores. Werbart et al. (2015) , for instance, observed that only three out of twenty patients with a nonimproved or deteriorated outcome also clearly indicated to be dissatisfied about treatment.

Nonetheless, the association between quantitative and qualitative evaluations of therapy and outcome remains unclear ( Timulak and Creaner, 2010 ). Mixed-methods studies have amassed in the past couple of years, though whether and how patients' experiences correspond to quantitative outcome evaluation is underexplored ( McLeod, 2013 ). The few studies that have been executed differ in the extent to which qualitative and quantitative findings show an accord (see Svanborg et al., 2008 vs. Klein and Elliott, 2006 ). The study of McElvaney and Timulak (2013) found only little differences between patients classified as “recovered/ improved” and “unchanged/ deteriorated” regarding their experience of therapy. As the strict demarcation of “poor” and “good” outcome does not appear in qualitative inquiry, questions can be raised about how representative such a statistical distinction is for the clinical meaning of outcome for individual patients (see Lambert and Ogles, 2009 ).

So far, the meaning of negative or poor outcome—distinguished by means of standard outcome measures—in relation to patients' subjective experiences, remains underexplored. As non-improvement and worsening are likely distinct phenomena with potential different clinical implications ( Mohr, 1995 ; Lambert, 2011 ), more focused investigations are required in order to grasp the phenomenon of non-improvement (in contrast to the approach of McElvaney and Timulak, 2013 , who studied unchanged and deteriorated cases together). In past endeavours, most of the studies have focused on deterioration or other “extreme cases,” yet little attention has been allotted to understanding treatment nonresponse or patient non-improvement specifically ( Lambert, 2011 ). Given the observation that lack of improvement occurs in a significant number of cases, and considerably more frequently than deterioration, this lack of attention is striking ( Lambert, 2007 , 2013 ). Importantly, gaining a better understanding of cases who seemingly have not moved forward or backward, will contribute to a more thorough and nuanced understanding of treatment-response and outcome in general. More specifically, this nuanced understanding is pivotal to elaborate the clinical meaning of outcome for patients themselves.

The integration of multiple methods and specifically the comparison of quantitative and qualitative methods is an indispensable development for the field of psychotherapy research ( McLeod, 2013 ; Bowie et al., 2016 ). The current study therefore provides a mixed-method analysis of patients suffering from major depression. Major depression is one of the most prevalent mental disorders worldwide ( WHO, 2017 ), and previous research has shown symptomatic evaluation of change alone cannot live up to the task of representing depressed patients' experience of outcome ( Zimmerman et al., 2006 , 2012 ). Based on this representative case, the present study aims to complement quantitative pre-post outcome scores indicating no reliable change in depression symptoms with a qualitative inquiry of depressed patients' perspective. In doing so, we move beyond the level of description (i.e., a lack of change in symptom scores) and toward a level of in-depth understanding (i.e., patients' subjective experience). Finally, instead of adopting a single focus on experiences of outcome or experiences of therapy, the present study aims to understand their interrelation as well as the broader context of potential influences, as these are typically not limited to therapeutic features alone ( Drisko, 2004 ; De Smet and Meganck, 2018 ).

The current study investigates how non-improvement in pre-to-post symptom severity can be understood in relation the experience of depressed patients themselves. We examine: (1) which potential changes patients have experienced and which factors can help to explain these changes from their perspective; (2) which potential issues remained and which factors can help explain these remaining issues according to patients; (3) how patients' perspective on non-improvement relates to the quantitative outcome evaluation of non-improvement (or no reliable change) in symptom severity. For the purpose of the study, the term “non-improvement” is used to indicate a specific definition of negative or poor outcome in accordance to the widely used statistical concept of a lack of reliable change in outcome scores (cf. Jacobson and Truax, 1991 ). We use this categorisation as a starting point to be able to broaden this influential framework of understanding, by nuancing it based on patients' perspectives.

Methodology

An explanatory sequential mixed-methods study was conducted, comprising a quantitative pre-post outcome evaluation as well as a qualitative analysis of nonimproved patients' perspective. The study is “explanatory” as the focus is on understanding non-improvement in-depth, and “sequential” because, even though quantitative and qualitative data were gathered simultaneously, both strands were analysed independently and integrated at the phase of interpretation. The design can be summarised as “quan → QUAL”: The qualitative analyses build on the quantitative outcome evaluation yet becoming the most important focus of the explanatory study; “the quantitative study (quan) is in service of the more dominant qualitative (QUAL) one” ( Hesse-Biber, 2010 , p.71). In the current study, a first phase comprised a quantitative outcome evaluation, based on which the target sample was selected. In a second phase, the corresponding interviews were qualitatively analysed. Integration and comparison of the two strands allowed for a better understanding of both the quantitative and qualitative outcome findings. Given the aim for in-depth exploration of patients' experienced changes, as well as understanding of the processes and factors that may explain those experienced changes, a grounded theory approach was selected as method of choice for the qualitative analyses ( Strauss and Corbin, 1990 ). Grounded theory can be used to provide description and interpretation, with the aim to generate conceptual models that can consecutively be translated into further hypotheses ( Fassinger, 2005 ; Charmaz, 2014 ). For our purposes, thus, this method seemed well-suited to build a thorough understanding of negative outcome and non-improvement from patients' perspective.

This study is based on data from the Ghent Psychotherapy Study (GPS), an RCT on the treatment of major depression; the trial has been registered on Open Science Framework (ISRCTN 17130982). For a specific description of the GPS context and methodology, we refer to the pre-registered study protocol ( Meganck et al., 2017 ). Patients in this study were recruited via social media and general practitioners in the area of Ghent, Belgium. Patients included in the study qualified for a diagnosis of Major Depressive Disorder, measured by the Rating Scale for Depression ( Hamilton, 1967 ) and Structured Clinical Interview for DSM-IV-TR ( First et al., 2002 ), both well-established and frequently used interview-based instruments in depression studies ( Nezu et al., 2000 ). The assessment interviews were conducted by six postgraduate research assistants trained in the respective procedures. Further eligibility criteria were sufficient knowledge of the Dutch language and age between 18 and 65; patients with a primary diagnosis of substance abuse, acute psychosis and suicidal ideations were excluded. Patients were randomly assigned to time-limited Cognitive Behavioral Therapy (CBT) or Psychodynamic Therapy (PDT). Patients progress was evaluated using questionnaires accompanying every session, interviews were conducted prior to treatment, around the eighth session and after treatment termination. The follow-up period of the study spans 2 years (ongoing) and consists of 4 interviews and quantitative assessment. This study was approved by the Ethical Committee of the University Hospital of Ghent University (Belgium; EC/2015/0085). All participants gave written informed consent in accordance with the Declaration of Helsinki.

Treatment consisted of CBT and PDT for major depression, two types of therapy that can be distinguished based on their directive (i.e., CBT) and exploration (i.e., PDT) style of interventions. Therapy was provided by one of four therapists in each approach. Both treatments were manualised and time-limited, consisting of 16–20 sessions. Treatment was delivered with an average frequency of one session per week; sessions lasted approximately 45 min. The CBT manual was based on the Cognitive-Behavioral Protocol for Depression by Bockting and Huibers (2011) . The PDT manual was based on the Supportive-Expressive Time Limited manual for Major Depressive Disorder by Luborsky (1984) and Leichsenring and Schauenburg (2014) . Therapists had an average age of 33 ( SD = 9.6) and had 3 to 8 years of relevant clinical experience and training in CBT or PDT. In the study, all therapists received 2 days of training, one patient to practice the treatment manual and the research procedure under supervision, and bi-weekly supervision sessions throughout the study.

Instruments

Beck depression inventory.

The Beck Depression Inventory (BDI-II-NL; Beck et al., 1996 ; van der Does, 2002 ) 2 is a measure of self-reported depression severity. The questionnaire consists of 21 items that are scored on a scale of 0 to 3 and is divided into a cognitive, somatic and affective subscale. A total score between 0 and 13 indicates minimal depression, 14–19 mild depression, 20–28 moderate depression, 29–63 severe depression. The questionnaire shows good validity and reliability ( van der Does, 2002 ).

Semi-structured Interview

An adjusted version of the semi-structured Client Change Interview (CCI; Elliott et al., 2001 ) was administered. The interview guide was constructed to evoke participants' experiences of therapy, the changes they believe occurred during therapy, and what they believe influenced these changes, for instance, helping and hindering aspects of therapy. Every interview started with the open questions: “How are you doing in general?” and “How are you feeling compared to when you started therapy?” Subsequently, patients were asked more specifically about experienced changes: “Which changes have you noticed since the start of therapy (e.g., in relation to others, at school/work, in your emotional wellbeing)?” and the role of therapy or other factors: “How did therapy contribute to these changes?” and “What other factors (outside of therapy) do you think have contributed to these changes?” Patients were also explicitly asked about negative changes or lack of change: “Is there something that did not change or that you would like to change in the future?”; “Did something change in a negative sense during therapy?” All interviews were conducted at the psychology department (Ghent University, Belgium) in the week following therapy termination. Interviews lasted 60 min on average. Interviews were audiotaped, and transcripts were analysed using Nvivo 11 (QSR International).

Quantitative Outcome Classification on the BDI-II-NL

Participants were classified in terms of reliable change and clinically significant change based on the Jacobson and Truax (1991) method for outcome classification. Patients self-reported symptom severity was measured prior to therapy and 1 week after treatment ended. The outcome scores of the patient population were compared to Dutch norms ( van der Does, 2002 ). In order to reach reliable change for the BDI-II-NL total score, a person must show a decrease in scores equal to or larger than 9.6. The cut-off between the clinical and nonclinical population for the Dutch BDI is set at 11.3 (based on the internal consistency of 0.92; van der Does, 2002 ). This leads to four possible outcomes: Clinically significant change (CS; a decrease in scores equal to or larger than 9.6 and post-treatment score below 11.3), reliable change (RC; a decrease in scores equal to or larger than 9.6), no RC (a decrease or increase in scores <9.6) and deterioration (an increase in scores equal to or larger than 9.6). In the total sample of the RCT ( n = 94), 31.9% ( n = 30) of the patients changed clinically significant, 20.2% ( n = 19) changed reliably, 23.4% ( n = 22) remained unchanged and 3.2% ( n = 3) deteriorated in scores on the BDI-II-NL; 21.3% ( n = 20) had missing outcome data (see Figure 1 ).

Figure 1 . Flow chart of sample selection.

Participants

For the current study, patients showing no reliable change in pre-to-post outcome scores on the BDI-II-NL ( van der Does, 2002 ) were included. We did not incorporate deteriorated patients based on the assumption that non-improvement and worsening are distinct phenomena with potential different clinical implications (cf. supra; Mohr, 1995 ; Lambert, 2011 ). For the same reason, we excluded patients who ended treatment prematurely (i.e., drop-out from treatment), which was defined as the patient-initiated premature termination of therapy within four sessions of treatment (in line with other commonly used definitions of drop-out; Wierzbicki and Pekarik, 1993 ; cf. Barrett et al., 2008 ) This resulted in the selection of 19 participants. The flowchart in Figure 1 gives an overview of the selection process for this study. The sample consisted of 12 women and 7 men ranging in age from 21 to 59 ( M = 34; SD = 10.7). All patients were born in Belgium except for 1 patient who was born in the Netherlands; 1 patient had a parent of foreign origin. Table 1 gives an overview of the demographic information per patient. During the study, 8 patients received CBT; 11 patients received PDT. Patients' average treatment duration was 17 sessions (range 6–20 sessions). All patients were diagnosed with major depression prior to treatment (comorbid Axis I diagnoses as assessed using the SCID for DSM-IV-TR are presented in Table 1 ).

Table 1 . Demographical information of patients in the sample.

Grounded Theory Analysis

Grounded Theory ( Glaser and Strauss, 1967 ) can be described as an explorative and interpretative qualitative research method, aimed at the construction of new theories or rationales grounded in data (in our case patient interviews) ( Fassinger, 2005 ; Charmaz, 2014 ). Using this method, a tentative conceptual model of non-improvement that comprises patients' experienced changes and explanatory factors was created Characteristic of grounded theory, several stages of analysis were completed in a cyclic manner before arriving at the final conceptual model ( Mortelmans, 2013 ). This form of inquiry enabled the exploration of the phenomenon of non-improvement in the participants' terminology and to identify themes in the data in a bottom-up manner. As the interviews were conducted in the context of a larger study, the interview questions were not altered throughout the data gathering process as is often the case in grounded theory analysis.

Prior to the actual coding of the interview transcripts, the first author wrote a vignette about every participant that included demographic information, treatment duration, pre-post outcome scores and a summary of the most important themes addressed in the interview. The vignettes were used to get an initial idea of the individual cases in the sample prior to the analysis. During later stages, the first author repeatedly reread the vignettes to validate the constructed model and conclusions with the individual cases. The interview transcripts were subsequently analysed by the first author in dialogue with the third author; the second author functioned as an auditor throughout the process ( Hill et al., 1997 ).

Open Coding

Open coding is defined as “the analytic process through which concepts are identified and their properties and dimensions are discovered” ( Strauss and Corbin, 1990 , p. 101). In this phase, the interviews were first read and reread to identify relevant parts of the interviews relating to the research questions (cf. selecting meaning units; Giorgi and Giorgi, 2003 ). Labels were attached to certain parts of the text, differentiating experienced changes/remaining issues from therapy factors and other mentioned influences. Non-relevant parts, i.e., not dealing with the topic of well-being, experienced changes or therapy, for instance, were omitted. In order to prevent relevant information from being omitted during the coding process, this work was first conducted on printed versions of the interview transcripts and repeated in the Nvivo software package. This phase resulted in a first list of codes that were formulated with the intent to remain close to the narrative of patients. A first rough classification was made between the various codes (i.e., experienced changes, remaining issues, therapy effects, social context). They were discussed between the first and third author and altered until consensus was reached.

Axial Coding

Axial coding can be summarised as “the process of relating categories to their subcategories termed ‘axial' because coding occurs around the axis of a category, linking categories at the level of properties and dimensions” ( Strauss and Corbin, 1990 , p. 123). In this phase, the various codes were further divided into subcategories in order to refine the first initial classification of codes. In dialogue between the first and third author, the resulting codes were thematically connected and where needed rephrased. At the end of this phase, the first author looked for visual images and metaphors that could help to grasp the central categories and mechanisms emerging from the narratives of the patients (e.g., “stuck in a maze”; “impasse”). These were further developed and refined in the next phase.

Selective Coding

Selective coding comprises “the process of integration and refining the theory” ( Strauss and Corbin, 1990 , p. 143). In this phase the theory was cultivated by creating a core category and building other categories around it. In discussion with the third author, this theory was refined. The second author audited the selection of the core and subcategories by asking critical questions regarding the rationale behind the extracted central mechanism. At the end of this phase a set of subcategories was created based on the entire nonimproved sample. Subsequently, we looked into the frequencies of the different categories represented in the CBT and PDT group in order to unravel therapy-related differences. These were included in a detailed table. After finalising the theory, adequate and valuable phrases were chosen to describe the categories and informative quotes were selected to illustrate the various categories and their interrelations and influences. Patients were given a letter of the alphabet to anonymise text fragments (i.e., from A to S).

Credibility

Credibility checks were held at several stages of the analysis. At the end of every interview, patients were asked whether they wanted to add further information that had not been addressed in the interview. During the analysis, we tried to remain transparent about the entire process ( Stiles, 1993 ) and we acknowledge the influence of the perspective and background of the researchers. The researchers' personal interest in patients' idiosyncratic perspective for instance instructed the focus of the study and analysis. Potential consequences of implicit guiding assumptions were controlled as much as possible by making this idiosyncratic focus central to our study ( Creswell and Miller, 2000 ). We furthermore departed from the assumption that “non-improvement” can also include changes, therefore this was explicitly integrated in our research questions. We worked in a systematic manner to form conclusions and interpretations ( Stiles, 1993 ) and attempted to stay open for any information coming from the narratives throughout the entire process. The analysis aimed at outlining macro-processes in psychotherapy, i.e., examining a wide angle rather than micro-processes (e.g., specific therapeutic effects) and investigated the subjective experience of several different participants (i.e., between-case variation) ( Denzin and Lincoln, 2005 ). In line with our research aim to investigate therapy and outcome in a broader context, the analysis and interpretation of patients' narratives were conducted using a contextual perspective that departs from the assumption that the broader social context influences how patients give meaning to their experiences ( Boyatzis, 1998 ). Triangulation among researchers, several interviews, and quantitative and qualitative indications of outcome were applied to gain different perspectives on the issue. The ultimate themes were formed by asking critical questions regarding codes and categories ( Mortelmans, 2011 ).

In this section, we will present the quantitative pre-post outcome data and qualitative analysis of patients' experiences respectively. Interpretations of the quantitative and qualitative findings will be described separately; broader integrative conclusions and implications will be presented in the discussion.

Descriptive Pre-post Outcome Scores on the Beck Depression Inventory

Table 2 summarises the average score on the BDI-II-NL ( Beck et al., 1996 ; van der Does, 2002 ) before and after treatment, the standard deviations (SD) and range in scores (i.e., minimum and maximum score) for the entire nonimproved sample, the PDT and CBT group.

Table 2 . Pre-post outcome scores on the BDI-II-NL.

Both at the start and end of therapy, the non-improved patient group is characterised by a wide range in scores. At the start of treatment, patients scores varied between moderate depression ( n = 10) and severe depression ( n = 9) (cf. van der Does, 2002 ). At treatment termination, 1 patient scored mildly depressed, 9 scored moderately depressed and 9 others scored severely depressed. The average score both before (30) and after (30) therapy indicate severe depression for the total sample, although at the borderline of moderate depression. All patients remained in the clinical range and did not change reliably in scores compared to the start of treatment.

Conceptual Model of Non-improvement From Depressed Patients' Perspective

The grounded theory analysis of nonimproved depressed patients' narratives resulted in the core category Stuck between “knowing vs. doing .” Around this core category, a model was constructed consisting of 10 subcategories that help to explain this core concept. The subcategories are divided into the changes and remaining issues patients mentioned and the positive and negative influences patients ascribed these changes/remaining issues to. These influences are referred to as “explanatory factors” and specified as “facilitating factors” and “impeding factors.” Figure 2 depicts the conceptual model: The left part of the model comprises positive changes and facilitating factors, the right part of the model shows remaining issues and impeding factors. Table 3 summarises all core and subcategories in more detail for the entire nonimproved sample, the PDT, and CBT group. The frequencies of patients contributing to each category were added.

Figure 2 . Conceptual model of non-improvement from depressed patients' perspective.

Table 3 . Taxonomy of non-improvement based on depressed patients' perspective.

Core Category: Stuck Between “Knowing vs. Doing”

The central mechanism for understanding non-improvement from the patients' perspective is “knowing versus doing”: A feeling of having acquired certain changes yet being unable to go a step further, or to know what the problem is but feeling an incapacity to do deal with it. In general, patients wanted to move forward but felt unable to. Some patients stated this literally: “Rationally I know what my problems are or what I should do, but there is just nothing changing.” At the same time, the core category captures the effects of therapy that on the one hand facilitated patients' self-understanding and mental stability, but on the other have not been able to overcome certain barriers. A plus (for positive changes and positive influences) and minus (for remaining issues and negative influences) seem to cancel out each other, resulting in a stalemate.

“I have learned a lot, I have gained many insights. (…) I am not as despondent anymore, but if I say that ‘not that much has changed' I mean, I still have difficult periods and a few fundamental problems, which I do understand better now, are not really solved yet, or maybe they are not easy to solve. So, I know much more, I have improved on the level of knowing, but not so much on the more practical level.” (Patient C., CBT)

Positive Changes

The overarching experience of being stuck does not imply that patients have not experienced changes at all. Two themes resulted from the analysis showing that throughout the process of therapy, patients have grown mental stability and strength ( n = 14) and have gained more insight ( n = 15). Moreover, these changes seem interconnected, as increased understanding was said to have influenced patients' personal strength. In the model in Figure 2 , this is indicated by a dotted line (showing interconnection) and an arrow from “Insight” to “Mental stability and personal strength.”

“In general, I feel much stronger, mentally. I have gained many insights in therapy. (…) It gave me peace of mind and recognition that okay, my thoughts, experience and things I long for are not that strange.” (Patient J., PDT)

Mental stability and personal strength

Increased mental stability ( n = 11) consisted of two subthemes: A more positive state of mind ( n = 9) and the ability to accept and let things go (n = 6). Patients had learned to deal with certain situations, they felt less emotionally overwhelmed and believed they could handle challenges better. Patients' personal strength ( n = 11) consisted of an increased self-confidence ( n = 11) and being more vigorous ( n = 9). Patients felt more active, dared to socially interact and felt less anxious and insecure.

Interviewer: “So you say you are mentally not dispirited anymore. Can you explain the difference with before?”

Patient: “I think that before I was really struggling with myself, my self-image and now I feel more balanced. I can take a distance. The fights [with partner] are still intense, but I relate it to the relationship now, I've stopped blaming myself.” (Patient Q., CBT).

Increased insight was described on three levels. Patients were able to see things from a different perspective ( n = 9), understood themselves better ( n = 8) and had gained insight into the reasons why they experienced difficulties ( n = 8).

“Therapy made me reflect upon things and gave me some different ideas about situations that were clear to me but might not have been that clear after all or that needed to be looked at from a different perspective.” (Patient A., PDT).

“I have learned more about myself. I already knew I was stubborn, but we talked about it a lot [in therapy], about how I set my standards very high and I don't accept help from anyone and that, by this, I make life very difficult for myself.” (Patient H., PDT).

Facilitating Factors

The facilitating factors contributing to these positive changes according to patients include the role of therapy, the therapist and the patients' social and professional context. As indicated in Figure 2 by unidirectional arrows, these features were described as contributing to patients' mental stability and strength as well as insight.

Therapy offers self-reflection and guidance

Patients in CBT and PDT presented slightly different experiences of therapy. These differences seem in line with the specific nature of both types of therapy, given the explorative and expressive style of PDT and the directive approach in CBT. Especially in the PDT group, weekly therapy sessions were considered important for being able to talk, express feelings and thoughts ( n = 6) and therapy was seen a as a weekly moment of self-reflection ( n = 11). This seemed to have stimulated both patients' insight (cf. self-reflection) and mental stability and strength (e.g., letting things out; relief).

“By saying things out loud in therapy, you start reflecting on them and it becomes a reality that does not only exist in your head. We had one session where the therapist asked some questions about my relationship and because I really did not want to answer them, I started wondering, how I really feel in this relationship, I realised that wasn't very good.” (Patient B., PDT).

In the CBT group, similar aspects were mentioned ( n = 4), but therapy was also valued for actively providing patients with insight and practical help ( n = 5), making the facilitating role of therapy more guiding than reflective.

“She [the therapist] helped me to take certain steps. We tried to come up with means to…, like a priority list for my day, because it is difficult for me to…, although I know I have to do lots of things, I'm not organised.” (Patient R., CBT)

Benevolent therapist approach

Patients in both therapy groups ascribed important changes more to the therapist's way of being than to the therapy form as such. Therefore, we explicitly describe therapy and therapist separately, even though the factors are clearly intertwined. This reciprocity is indicated in the conceptual model ( Figure 2 ) by means of a bidirectional arrow. Firstly, a good therapeutic relationship was described by the majority of patients ( n = 16) as making it easier for them to talk and open up. More specifically, patients valued that the therapist did not judge but rather encouraged and acknowledged them ( n = 10). Secondly, the therapist had the skill to ask the right questions ( n = 15) that stimulated reflection and provided patients with a different perspective. The previously discussed themes “insight” and “mental stability” were described as influenced by this approach of the therapist. Although the therapist was mentioned as important in both CBT and PDT, the nature of the experienced role of the therapist's different: In PDT, the therapist was described as stimulating a mental process that was ongoing for the patient, while the CBT therapist was characterised as being an active participant or initiator in the therapy sessions.

“His questions, they often appeared so innocent, but when you think about it afterwards you see things from a different perspective. Very subtle because he does not tend to give his own opinion.” (Patient C., PDT).

“After a few sessions, my therapist came up with a scheme that summarised my life until now and where my anxiety comes from. I remember I had to cry for the first time. I noticed how good it felt to finally be understood. I still believe he can help me in the process of accepting it [certain life events].” (Patient S., CBT).

The context as an important impetus

Besides therapy and the therapist, patients mentioned the influence of their social context as a third facilitating factor. Significant others appeared as an important motivation to do something about problems, to find a job or to keep on going ( n = 11). For some patients, it had been important to be at home for a while (with sick leave) and to have the time for themselves in their own space ( n = 10). For others ( n = 5), work (i.e., the professional context) was an important support mechanism, as it gave them a reason to get up in the morning and structure to their day. The motivating context was therefore considered a facilitating factor for patients' mental stability and personal strength and seemingly a potential stimulus for engaging or continuing treatment.

“My son is one of the reasons for starting and continuing the course [i.e., education]. I want to be able to show him something, instead of being an unhappy person. I want to give him something, something positive. That's actually the only valuable thing in my life that's left. I used to be so materialistic, now the only thing that matters is him.” (Patient L., CBT).

Remaining Issues

Despite the positive changes in mental stability, personal strength and gained insight, certain issues remained. Feeling stuck was characterised by the wish or ambition to change yet feeling unable to do so. A reciprocal arrow between the categories “Ambition to change” and “Inability to change” represents this equilibrium.

Ambition to change

The majority of the patients experienced an ongoing struggle and carried hopes for further change ( n = 13). These aspects implied things they believed they still lacked or they should work on in the near future, such as tackling self-criticism and self-discipline.

“I wish I could have a more positive stance in life, to be able to counter my negative thoughts. I want to have the discipline to get things done, but the hours just slip away, I see the days pass by without getting anything done. That's wasted time to me. I want to get a grip of it.” (Patient I., PDT)

Inability to change

In spite of and seemingly in conflict with the ambition to change is an overall feeling of inability ( n = 13). Patients felt as if they were running behind on things, they lacked initiative and could not force themselves to move forward.

“I'm just not on top of things. I constantly feel rushed, but I lose so much time. Searching for things, not able to finish things because you are too distracted. I just can't seem to get out of it. Things pile up, it seems that for every problem I solve I get two in return” (Patient P., CBT)

Some patients described an inescapable cycle they seemed to repeat over and over again ( n = 3). This inability was also reflected in what seemed like an internal conflict ( n = 7), for instance, being stuck in the struggle between wanting to spend more time with the kids but at the same time aspiring for a professional career. One patient was highly preoccupied with a long-lost dream, which made it impossible to pursue a new goal in life.

Impeding Factors

Similar to the factors that help explain positive changes, patients brought up potential reasons for why certain issues remained unchanged. These factors include the limits of therapy, the role of the patient and a negative influence coming from patients' social context.

Therapy hits its limits

Notwithstanding its positive effects, therapy was described as hitting a limit by all patients. More specifically, advise or learned techniques were considered valuable, yet only up to a certain point. Patients stated that they were unable to use the techniques when feeling really bad, or they did not find the time to do so. For others, therapy had progressed too slowly, had not been valuable every session, or it had worked for some aspects but not for others. Therapy hit a limit in two ways: Something was missing in therapy ( n = 12) and/or the therapy mismatched the patient's needs or expectations at some point ( n = 17). Noteworthy is the observed difference between the PDT and CBT group. A few patients in PDT were displeased that they had not gained the right tools, were not given any directions ( n = 4) or stated therapy had a varying impact (sometimes it helped, sometimes it did not) ( n = 3).

“I expected her [the therapist] to give me good advice on how to deal with my problems. How I can worry less, how I can improve my breathing, just some tips. I must have imagined therapy the wrong way, she did not give me any tips. I'm kind of disappointed. (…) I still don't understand the purpose of talking about all these things, I often felt worse after the session.” (Patient G., PDT).

Some patients in the CBT group, on the other hand, stated therapy was too superficial and they needed a more intense form of treatment ( n = 5).

“The first three to four sessions, you tell your whole life story and all that is said about it is just okay, ‘you suffer most from the discussions [at home/with your partner] so let's see how we can handle them.' While I thought okay, I just told you my entire life story, about who I am and how I became who I am, that could have been included in therapy, but I actually felt that it wasn't at all, we just looked at one segment.” (Patient Q., CBT).

Moreover, therapy as hitting its limits seems to have contributed to a rather ambivalent attitude toward possible continuation of therapy ( n = 11). One third of the patients had no further need or motivation to continue psychotherapy ( n = 8). Some of them believed they had dealt with everything or had gotten everything out of therapy that they could, others had lost hope that therapy could help them or were disappointed about the results. Half of the patients indicated they would continue the same therapy, because they felt committed to the process ( n = 6) or because they had further specific issues they wished to address ( n = 4). Others, however, were interested in pursuing a different kind of therapy ( n = 7).

The patient's resistance and impossibility

Patients also reflected on their own role and position in therapy. Most patients described feeling a certain resistance toward therapy ( n = 16). For instance, they did not take therapy very seriously, had difficulties with opening up or were reluctant to do certain exercises. Several patients saw therapy as a task or an investment that asked too much from them (e.g., energy, time, money) ( n = 6). This rather ambivalent position in therapy was, for instance, described by patient R:

“I was afraid to fail in therapy. (…) I typically start things but can't manage to continue them. Maybe because (…) when it hasn't gone well one day, I can't let that go. It is all or nothing often, so I was afraid I would not do very well [in therapy] and also, sometimes I put effort into it, but often I was busy doing other things I thought I should be doing, like work.” (Patient R., CBT).

Secondly, many patients were convinced about the fundamental nature of their problems and the impossibility to change ( n = 15), sometimes referring to their own personality. Moreover, some patients indicated that therapy of 20 sessions is in general too little to solve more fundamental problems. The patient's resistance and idea of impossibility seem to correspond to the perspective on therapy as hitting a limit. In Figure 2 this was indicated by means of a reciprocal arrow, assuming a certain reciprocity between both explanatory factors.

“I think I'm quite a different case, I have quite a big tendency toward depression, if I compare myself to other people in my environment who have depression, they get over it after a year, but I think for me this is a bit more difficult, because of my childhood…I have been conditioned to think in a certain way, I think that matters a lot [for the duration and effect of therapy].” (Patient O., CBT).

Despite a mismatch, some patients described they were able to get passed initial resistance and adjusted to therapy, while for others, the limits of therapy, their own resistance or feelings of impossibility lasted throughout the therapy process.

“I might have expected therapy to be a bit more practical, but I noticed quite fast that this wasn't the goal of the sessions and I accepted that, I didn't see the talking as a waste of time” (Patient I., PDT).

“So, I think ‘okay, therapy has ended now and once again I'm nowhere, it did not help, and it only cost me money, a lot of time and energy, and why? For nothing.' (…) Of course, I know I did make progress, but I it's hard for me to see it that way. I just think, ‘it's the umpteenth thing I've tried and what is the use?”' (Patient P., CBT).

The context as a source of distress

Several contextual factors were mentioned as having a negative influence on patients' wellbeing during and after therapy. Firstly, patients' personal context was mentioned as being highly stressful ( n = 16). Several patients, for instance, encountered a conflict with family members ( n = 6). These difficulties in relationships were often considered to facilitate or perpetuate certain problems, and consequently they were believed to have influenced the therapy process and patients' progression. Patient F., for instance, described a critical moment in course of therapy:

“There was a crisis [during treatment]. It was when I just started working there [family business], it became too much with how my brother-in-law always got angry with me. I could not handle it. He yelled at me that I was making him bankrupted, I cost a fortune, I don't work well, I'm too slow. At a certain point I switched off my phone and just ran away, I wanted to disappear, commit suicide.” (Patient F., PDT).

Secondly, the professional context appeared as a source of stress or dissatisfaction ( n = 9). This subtheme contains patients who experienced high amounts of stress due to school-related deadlines, had difficulties adjusting to a corporate culture (e.g., not able to handle the given freedom) or did not experience any fulfillment at work. Finally, many patients mentioned external factors causing distress, like certain events or circumstances ( n = 12), for instance, dealing with unexplainable physical complaints and an ongoing lawsuit. The reciprocal arrow in the conceptual model between the patient's resistance and impossibility and stressful context indicates that both factors are understood as interacting and influencing the therapy and recovery process.

This study investigated the phenomenon of non-improvement in psychotherapy from the perspective of depressed patients in relation to their pre-post outcome scores showing no reliable change. By doing so, we answered the pressing need for further investigation of the phenomenon of negative outcome and the exploration of the relationship between quantitative and qualitative approaches to outcome and treatment evaluation in the field of psychotherapy ( McLeod, 2013 ).

First and foremost, the findings of this study showed that non-improvement as indicated by symptom-based outcome scores did not mean that patients did not experience any changes. Where a lack of change in outcome scores means a status quo on the level of symptom-severity, the interviews of the patients revealed a more nuanced and complex picture. Central to patients' experience of non-improvement is the mechanism of knowing vs. doing. While patients had the ambition to change, they felt unable to overcome certain problems, resulting in a stalemate of knowing what to change but not being able to. Positive changes were offset by substantial remaining issues: Increased mental stability, personal strength and insights were gained, yet these did not result in changes on other levels of patients' lives. From the patients' perspective, “no change” in symptom-based outcome scores seemed to be “not enough” change or a “partial change.” The therapy, the therapist, the patient and context facilitated positive changes but at the same time were unable to alter important issues or even impeded patients' progression (resulting in remaining issues). None of these factors can be considered the main or only explanatory reason but must be understood as interacting (cf. Mash and Hunsley, 1993 ; Werbart et al., 2015 ). In sum, an equilibrium between a positive and negative pole seems to characterise the depressed patients' experience of non-improvement.

A similar positive-negative balance has been observed by Werbart and colleagues in a study on non-improved patients' experience of psychotherapy (2015). Nonimproved patients perceived their therapy as “spinning one's wheels”: Therapy was valued for some aspects but disappointing on others and even though some changes occurred, core difficulties remained. The current study investigated nonimproved patients' experiences of outcome and therapy in a broader context of various potential explanatory factors (i.e., not limited to the effects of therapy). In that sense, the findings of this study and the study of Werbart et al. (2015) can be seen as complementing each other, also because different populations of patients were investigated (i.e., adults and young adults). Notably, the experience of both outcome and therapy are strongly congruent in reflecting a balance between a plus (i.e., positive changes and facilitating factors) and minus (i.e., negative changes/remaining issues and impeding factors).

The positive pole of the resulting conceptual model in this study, including increased mental stability, personal strength and insight, corresponds to findings of other qualitative outcome studies. Mental stability and personal strength relate to what has been described as feelings of empowerment and improved emotional functioning ( McElvaney and Timulak, 2013 ), and more generally, as changes on the level of the self ( Timulak and Creaner, 2010 ). Strikingly and in contrast to findings from studies on patients' experience of positive outcome, our nonimproved sample did not report changes on an interpersonal level ( Nilsson et al., 2007 ; Binder et al., 2009 ; Timulak and Creaner, 2010 ); reported positive changes were overall more self-focused. Indeed, we could wonder whether improvement on a symptomatic level enables or coincides with changes on a more interpersonal level. Regarding patients' gained insight, our findings seem partially in contrast to the commonly derived conclusion that insight is an important acquisition for obtaining positive outcome (see the recently published meta-analysis of Jennissen et al., 2018 ). In this study, increased insight facilitated patients' mental stability and personal strength, but it did not alleviate patients' self-reported symptoms or alter core difficulties. Similarly, Lilliengren and Werbart (2005) found that self-knowledge does not always coincide with changes in underlying problems. Qualitative studies suggest an important role for agency regarding this link between insight and outcome: Rather than gaining insight as such, it is important to gain the capacity to apply or act upon gained insight in daily life ( McLeod, 2013 ) 3 . Stage models of therapy (see for instance Hill, 2004 ), state that insight is only valuable to the extent that it leads to action. The absence of this active component could explain the lack of improvement on other levels in our research sample. As already stated by Freud, in order to gain substantial change, a step beyond intellectual insight toward experience might be required (see Bohart, 1993 ; Castonguay and Hill, 2007 ). More research on the mechanism of how insight promotes change is, however, warranted.

The helping role of treatment differed depending on the type of therapy. In accordance with the finding of Nilsson et al. (2007) , patients valued CBT and PDT for different reasons. In our study, therapy provided a moment of self-reflection for patients in the PDT group, while practical help and guidance was valued in the CBT group. Interestingly, while patients in both CBT and PDT mentioned the central role of the therapist, its specific effectuation differed seemingly. In line with the differentiation between the approach of the respective therapies, the PDT therapist was attributed a rather subtle though powerful technique stimulating reflection in patients. The CBT therapist, on the other hand, was considered an active participant in treatment who offered patients insight via tools such as schematic overviews. A good therapeutic relationship was one of the most important common factors in psychotherapy ( Lambert and Barley, 2001 ) mentioned by the majority of the patients in our study, similar to other qualitative findings ( Levitt et al., 2016 ).

Nonetheless, all patients stated therapy hit a certain limit. Again, in line with the observation of Nilsson et al. (2007) , both types of therapy were criticised on a different basis: In our sample, dissatisfied patients criticised CBT for being too superficial while PDT was criticised for not offering the right tools or direction. The latter corresponds to findings from the study of Lilliengren and Werbart (2005) , in which patients experienced similar disappointments in psychoanalytic therapy (e.g., wanting a more active therapist, guidance, feedback, and advice). A possible mismatch between certain patients' needs or expectations and the type of therapy supports the increasing emphasis in research to explore which type of therapy works best for whom and focus on the tailoring of treatment to patients' transdiagnostic characteristics ( Norcross and Wampold, 2011 ).

Beyond therapy hitting limits, patients in this study mentioned explicitly that they themselves encountered a certain resistance or hit their own limits and limitations. The patient's in-therapy behavior, such as client involvement and motivation, is the single most important predictor of outcome. Patient motivation has moreover been linked to expectations and hopefulness: Patients who do not believe they can change, and who feel hopeless, may have less motivation to participate in therapy ( Bohart and Wade, 2013 ). Accordingly, the participation in the therapy process seemed rather ambivalent in our sample. Notably, individual differences were observed: Some patients were able to get passed initial doubt about the therapy approach and their own ideas of impossibilities, while others did not. Although not mentioned by patients themselves, it is important to consider that many patients in the sample presented with one or more comorbid disorders, in most cases some kind of anxiety disorder at the start of therapy. Previous research has shown comorbidity in general predicts worse outcome (see Lambert, 2013 ).

Finally, our findings revealed the therapy process was intertwined with influences from outside the therapy room. Patients' personal context was both considered an important motivation as well as a large source of distress. Again, opposite effects facilitated and impeded changes. It has been outlined that the context plays a central role in sustaining involvement in psychotherapy or undermining this effort ( Lambert, 1992 ; Drisko, 2004 ). The impact of patients' professional context on their well-being mentioned in this study is in line with robust findings on the impact of job satisfaction on mental health ( Faragher et al., 2005 ). Whilst most qualitative studies tend to focus specifically on patients' experience of psychotherapy, our study provides a valuable additional element of contextualisation.

The resulting negative pole of the conceptual model of non-improvement, including the ambition yet inability to change, shows resemblance to what is considered a central characteristic of experiencing depression: Running behind on things, lacking initiative and motivation (DSM-5; APA, 2013 ). Feelings of hopelessness and helplessness were unresolved, in line with the remaining average score of severe depression in the sample. However, the question should be posed whether this feeling remained unaltered or rather emerged throughout the process of therapy, for instance, as a response to a lack of improvement. A pre-post research design, even when including retrospective inquiry of patients' experiences prior to treatment, falls short in answering this question. Longitudinal research that includes patients' experiences at the start of therapy as well as monitors changes throughout the process of therapy is needed (cf. De Smet and Meganck, 2018 ).

The contextual model of psychotherapy as described by Wampold and Imel (2015) , offers a valuable framework for interpreting our research findings. In this model, therapy is perceived as a “socially imbedded healing practice” (p. 258) in which the relationship between the therapist and patient is central. According to this model, three pathways lead to change in patients' wellbeing: The first pathway establishes the personal relationship (“real relationship”) between patient and therapist, characterised by genuine interest and empathy, the second pathways creates expectations in patients of being able to overcome their difficulties, and the final pathway includes therapy specific features or tasks. Although all three pathways lead to a certain degree of change, central for the therapy to work is that it can engage patients to follow the treatment rationale and overcome personal beliefs and explanations for distress.

Regarding the first pathway, the contextual model assumes that establishing a real relationship with the therapist leads to general well-being rather than symptom reduction ( Wampold and Imel, 2015 ). Correspondingly, we observed an increased mental stability and personal strength while patients remained unchanged on a symptomatic level. Patients' pessimistic expectations regarding improvement moreover remained unaltered and for many it was difficult to adapt to or engage in specific therapy features; the second and third pathway thus seem not (entirely) fulfilled. The dyadic concept of the patient-therapist working alliance ( Bordin, 1979 ) further demonstrates how “the collaborative purposive work” ( Hatcher and Barends, 2006 , p. 293) was obstructed by this discordance between patient and therapist or therapy; both by therapy not being able to meet patients' need, as well as by patients' resistance toward the requirements of therapy. This links up to the differentiation between two types of bonds: The work-supporting bond and personal relationship (cf. real relationship). The latter involves affective attachment, liking, trust and respect. The other type of bond is considered necessary for “the difficult work” in therapy, for instance dealing with affective or painful material or executing assignments like exposure and homework ( Bordin, 1979 ). This distinction helps to understand how, in our study, patients experienced a good therapeutic (or real) relationship but failed to engage in the work-supporting bond. Being at ease in therapy and feeling accepted and understood by the therapist thus seem important, for instance leading to increased well-being ( Wampold and Imel, 2015 ), mental stability and personal strength, though not enough to facilitate further life-changes. Correspondingly, gaining insight or self-understanding as such might not be enough when “the hard work” of dealing with affective material has not been worked through. While the contextual model ascribes most of the responsibility to the therapist, the current study and findings give more weight to the role of the patient and his personal context ( Wampold and Imel, 2015 ).

These findings yield a number of clinically relevant implications. Patients who find themselves stuck between knowing versus doing, may hit a certain limit due to a mismatch with the therapy offer, experiencing personal resistance or encountering difficulties outside of the therapy room. As these implications may be brought about by (idiosyncratic) underlying reasons, it may be worthwhile to take this as a particular clinical focus. In light of the increasing use of routine outcome measures in clinical care (see Boswell et al., 2015 ), a lack of changes in symptom severity could indicate any of these reasons and most likely a combination, yet monitoring instruments clearly require further exploration in dialogue with the patient. However, signs of non-improvement may not always be visible for the therapist. Studies have shown that therapists tend to underestimate negative outcome, as patients tend to keep dissatisfaction about therapy to themselves—possibly because they do not want to offend the therapist ( McLeod, 2013 ; Werbart et al., 2015 ). Therefore, it may be implicated to work on meta-communication in therapy, to avoid or restore possible ruptures in the therapeutic work and relationship ( von Below and Werbart, 2012 ). On the other hand, a well-established therapeutic relationship could change dissatisfaction about therapy into a negotiation, that is, an active focus point in therapy (cf. Wampold and Imel, 2015 ). In some cases, referring patients to a different approach that is more in line with patients' own rationale may be warranted ( Wampold, 2007 ), as what may work for 1 patient, might not work for the other ( Norcross and Wampold, 2011 ). Also, the optimal duration of treatment may differ among patients. In the current study, the number of sessions was fixed at twenty, which may have been too little to facilitate changes for some patients (e.g., the average “good enough level” has been estimated at 26 sessions; Barkham et al., 2006 ). Moreover, patients showing high levels of resistance in therapy may benefit from a less directive approach (see Beutler et al., 2002 , for an overview of the literature on resistance) in which therapy is adjusted to patients' own pace. This is supported by authors who warn that uniform time limits for treatment may not adequately serve individual patients' needs ( Baldwin et al., 2009 ).

This study addresses the critical concern about misrepresentation of patients' outcome by means of standard outcome evaluation and statistical classification ( Kazdin, 2008 ; Hill et al., 2013 ). First of all, no reliable change in outcome scores seemingly masked the significant changes experienced by patients and does not allow to represent the particular balance between remaining issues and positive changes. Furthermore, considering patients to be a uniform group based on a similar pattern of outcome scores might overlook important individual differences. None of the patients in our sample stated they were cured, although they did vary in the extent to which they experienced improvement and whether they wanted to continue treatment. In our study, the pre-post changes in outcome scores seem to give a rough preliminary indication of patients functioning, while the patients' narratives show non-improvement is more complex and diverse than can be grasped by a lack of symptom reduction (in line with Zimmerman et al., 2006 , 2012 ). This observation is not surprising in light of the complexity and heterogeneity of depression experiences ( Ratcliffe, 2014 ). It is plausible to assume that recovering from depression is at least equally diverse and layered (cf. von Below et al., 2010 ).

Consequently, the findings of this study shed light on the previously voiced question of how negative outcome and non-improvement should be conceptualised. In general, similar to previous research findings, patients' treatment satisfaction and negative outcome did not show a one-on-one correspondence ( Werbart et al., 2015 ); while all patients stated therapy hit a certain limit, a minority was also clearly dissatisfied. Mash and Hunsley (1993) have argued that “without a guiding theoretical framework for considering failing treatments, the assessment task is daunting, because almost any event in therapy might be construed as a possible indication that treatment is currently failing or is about to fail.” (p. 293). This study shows how this endeavour benefits from a mixed-methods research format that integrates a grounded theory approach. In line with the strengths of grounded theory ( Fassinger, 2005 ; Mortelmans, 2011 ; Charmaz, 2014 ), further theory-building research can mean an important contribution here (cf. Stiles, 2015 ).

Strengths, Limitations, and Future Directions

The implications of this study address the well-known gap between academic research and clinical practice ( Castonguay et al., 2013 ). RCTs as golden standard research format are limited in providing knowledge that can inform clinical practice ( Westen et al., 2004 ). The value of integrating qualitative research into this type of rigorous research has therefore been emphasised ( Midgley et al., 2014 ). The current study provides an actual example and informs both clinicians and research on the relationship between outcome scores and patients' experiences of non-improvement. It furthermore builds on the literature of helping and hindering therapy features ( Paulson et al., 2001 ; von Below and Werbart, 2012 ) by placing the experience of therapy in a broader context of potential explanatory factors as mentioned by patients.

The current study is one of few examining the relationship between quantitative and qualitative outcome evaluation of non-improvement ( McElvaney and Timulak, 2013 ; McLeod, 2013 ). Focusing on this particular subgroup rather than deteriorated or dissatisfied patients allows for the contribution to a lack of specificity in outcome research and the literature on negative outcome ( Lambert, 2011 ). Research suggests non-improvement, deterioration and patient satisfaction do not fully correspond, although they are often used interchangeably ( Lampropoulos, 2011 ). The current study gives an overall conceptual model of non-improvement and potential explanatory factors. Whether this is, however, representative for nonimproved depressed patients cannot be concluded. Further research should focus on investigating differences and similarities between various groups of outcomes (cf. recovery, improvement, no change, and deterioration; Jacobson and Truax, 1991 ) in order to get a better understanding of the clinical meaningfulness of change from the perspective of patients.

This study contributes to the understanding of non-improvement in psychotherapy and the relationship between quantitative and qualitative outcome evaluation. It cannot, however, answer the question whether outcome scores were representative for every individual patient. The focus of the present study was to provide an overall understanding, (i.e., a conceptual model) of non-improvement relying on a larger group of nonimproved patients. More idiosyncratic information still remains unaddressed and case-study research focusing on individual patients' narratives and outcome scores is warranted ( Kazdin, 2011 ). Similarly, the study cannot offer a fine-grained comparison of the specific effects of CBT and PDT, which could be further addressed in research on specific factors. The mixed methods research format in our study furthermore explicitly favoured the qualitative data over the quantitative outcome classification as focus of investigation, limiting the quantitative strand to a single, although psychometrically sound and often used, outcome measure. Our selection of patients based on self-reported symptoms nevertheless, had a considerable impact on our findings. With use of other means for categorisation, the sample likely would have turned out differently (e.g., using a different measure, multiple measures or relying on patients' satisfaction). Yet, as the use of statistical classification of clinically meaningful outcome (cf. Jacobson and Truax, 1991 ) is increasingly common in RCTs and standard outcome research at large ( De Los Reyes et al., 2011 ), this study explicitly aimed to relate the exploration of patients' experiences to the much-used classification tool. Therefore, the aim of the current study was not to address the issue of measurement as such, nor the validation of the specific questionnaire that was used, but to deepen the understanding of outcome that is gained by these much used categories. Our conclusions on the relation between quantitative and qualitative appraisals of outcome can however not be generalised to the entire field of quantitative outcome evaluation that undoubtedly has evolved in the past decades, for instance with an increasing focus on person-centered questionnaires ( Elliott et al., 2016 ). For the purpose of our study, an explanatory sequential design was most suited ( Hesse-Biber, 2010 ). Nevertheless, further research aiming at different approaches to mixing methods and including idiosyncratic quantitative outcome evaluation could contribute greatly to our knowledge on outcome and psychotherapy.

Given the controlled context of our study (as data was collected in the context of a broader RCT), it offers a strong level of control for confounds. For instance, the research sample was characterised by a primary disorder of major depression, outcome was systematically evaluated in all patients and treatments were manualised. A potential threat is therefore, however, the external validity of the findings ( Westen et al., 2004 ). Unlike in naturalistic studies, patients with more complex and acute psychopathologies were excluded. Nonetheless, all patients in our study showed comorbid disorders in line with clinical reality; for instance, the co-occurrence of major depression and anxiety disorders observed in this study is a robust finding throughout patient groups (cf. Hirschfeld, 2001 ). The participants in this study resembled a homogenous and local (predominately Caucasian, Flemish) group of patients, however. Specific (e.g., cultural, ethnic) or more diverse groups of patients could be the focus of complementing research. The research findings might also be biased by a selection of patients willing to participate in the study. Moreover, it is known that patients do not easily disclose negative experiences with therapy or with their therapist, and although interviews can enhance this openness ( McLeod, 2000 ), in general, socially desirable answers cannot be excluded ( Thurin and Thurin, 2007 ).

The model of nonimproved outcome must be considered tentatively, and we do not wish to make strong causal claims regarding the effectiveness of treatment or the causal influence of the therapist. In agreement with Strupp and Hadley (1977) , we emphasise that the patient perspective is only one perspective on outcome (e.g., in addition to therapist or societal perspectives), and therefore highlights certain elements while neglecting others. This limits the findings of this study, as previous research has shown patient, therapist, and observers' perspectives on outcome not always converge and all add valuable insights for clinical practice ( Altimir et al., 2010 ). Nevertheless, integrating in-depth inquiry of patients' narratives in the form of mixed methods research is of considerable value to outcome research and the study of non-improvement. In general, we argue that further research investigating the complex phenomena of outcome and therapy effects should aim at an integration of multiple methods as well as perspectives to grasp the wider picture ( McLeod, 2011 ).

Non-improvement in psychotherapy from the perspective of depressed patients can be understood as being stuck between knowing versus doing, resulting in a stalemate. Patients described both positive changes on the level of insight, mental stability and personal strength. The remaining issues were characterised by an ambition to change but feeling an inability to do so. No change in depression symptoms based on standard pre-post outcome evaluation thus becomes a partial change when considering patients' experience and shows a more complex picture in line with the complexity of experiencing depression. Investigating non-improvement by integrating in-depth analyses of patients' narratives in the form of mixed methods research proves to be of considerable value for understanding (negative) outcome and treatment effects more general.

Author Contributions

MDS: main author of the manuscript, contribution to data collection, main investigator responsible for data-analysis and interpretation; RM: conception and development of study design, coordinating contribution to data collection, contribution to data-analysis and interpretation, main reviewer of the manuscript; KV: contribution to data collection, contribution to data-analysis and -interpretation, reviewer of the manuscript; FT: contribution to data collection and reviewer of the manuscript revision; MD: conception and development of study design, coordinating contribution to data collection, reviewer of the manuscript.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgements

We want to thank all patients and therapists for participating in the study. Acknowledgements to Ufuoma Norman for the careful reading of the final draft of this manuscript. Gratitude for contributing to the data collection for the Ghent Psychotherapy Study goes to Ruth Inslegers, Rosa De Geest, Goedele Hermans, Vicky Hennissen, and Ufuoma Norman. MDS is funded by the Flanders Research Foundation (FWO, Belgium).

1. ^ Note of nuance: as outcome is predominantly evaluated by means of symptom-based scales ( Braakmann, 2015 ), throughout this paper we will refer to a decrease in symptoms, even so we acknowledge outcome measurement is not limited to symptom-based scales but can also contain measures of general wellbeing, satisfaction and interpersonal functioning.

2. ^ Given the focus of the current study on patients being treated for major depression, the BDI-II-NL was selected as the outcome measure in this study. A complete overview of all measures used in the GSP can be found in the study protocol ( Meganck et al., 2017 ).

3. ^ See McLeod (2013) for a summary of qualitative studies on this topic, Bohart and Wade (2013) on the role of agency, Castonguay and Hill (2007) for an elaboration on the role of insight in psychotherapy.

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Keywords: non-improvement, psychotherapy, outcome research, grounded theory, depression-psychology, mixed-method analyses, qualitative and quantitative methods, patient perspective

Citation: De Smet MM, Meganck R, Van Nieuwenhove K, Truijens FL and Desmet M (2019) No Change? A Grounded Theory Analysis of Depressed Patients' Perspectives on Non-improvement in Psychotherapy. Front. Psychol . 10:588. doi: 10.3389/fpsyg.2019.00588

Received: 28 September 2018; Accepted: 01 March 2019; Published: 26 March 2019.

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*Correspondence: Melissa Miléna De Smet, [email protected]

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