(From the EiC: This is part of our ongoing series on health professions education research. For: Critical Discourse Analysis; Validity; Pre-Post Simulation; RCT; Education Research, Retrospective Cohort Studies)
You are a clinical teacher realizing your medical students are struggling to understand the concept of acid-base balance and how it transfers from basic science to clinical practice. You suspect that it has something to do with the students’ inabilities to change perspective and adopt a clinically relevant understanding of the concept. You want to facilitate the “transfer” of knowledge but realize that you must first understand the different forms of understanding that exists among them and the nature of a basic science understanding of the concept.
In this blog we are introducing phenomenography as a qualitative approach to answer some of the questions we may ask ourselves as medical educators and scholars, to be able to improve our practice. (For an overview of qualitative research design we recommend this KeyLIME podcast as a starting point: http://keylimepodcast.libsyn.com/140-10-minute-primer-on-qualitative-methods-with-guest-host-lara-varpio.)
Phenomenography (not to be confused with phenomenology) is the empirical study of the variation in ways in which people understand or experience phenomena in the world around them and how these ways of understanding are logically and hierarchically related to each other and to the perceptions of the situation in which they are experienced. The focus on variation is one of the strengths of a phenomenographic approach, which has been used in studies exploring for example the multiple ways in which medical students experience interactions during a patient encounter, how patients understand living with a certain illness, how physicians understand asthma treatment or diabetes care, what it means to be a palliative nurse or a mentor, or the differences between how patients and health care professionals understand the implications of having a stroke.
Data collection and analysis
Interviewing is the primary method for phenomenographic data collection, although written texts such as responses in exams, or drawings also have been used. As the aim in phenomenography is to capture the range of possible ways in which a certain phenomenon is understood within a group, respondents are selected to maximize variation. The interview guide consists of a relatively small number of open ended questions followed by different kinds of probing.
Depending on the phenomenon under study, certain content expertise may be necessary for the interview and the analysis. However, as a content expert in, for example physiology or anesthesiology it may be more difficult to see past the expert view when analyzing the transcripts. Team members who are well versed in qualitative research should therefore ideally perform a parallel analysis to content experts so that the findings can be compared and discussed.
The analysis of the data in a phenomenographic study is iterative, not too dissimilar from the process used in many other qualitative approaches. As part of the analysis, a number of categories representing different ways of understanding the phenomena are developed. Then, the relationships between the categories are identified. The assumption of a structural (often hierarchical) relationship between the categories is one of the core assumptions of phenomenography. The categories do not necessarily represent certain respondents, as a descriptive collection of such unique conceptions is considered less useful when it comes to guiding for example educational change, than the related categories that a phenomenographic analysis provides. Instead, the focus is on qualitative differences and critical variations in ways of understanding and the relationships between these ways.
The usefulness of a phenomenographic study
People can interpret the same events and situations in many different ways (even if we often feel that our own way is the only reasonable one). Phenomenography makes it possible to view variation in experience holistically, through the structural relationships between the categories. It can be used to enable and support change, or inform and influence practice. In other words, answering the dilemma stated at the top of this blog, clinical teachers will benefit from a better understanding of how students may conceptualize the phenomena they teach. Phenomenography can help bring to the surface and define different perspectives so that these can be compared, contrasted and scrutinized. A deep understanding of the possible differences in ways of conceptualizing something can help teachers support learning by building on this understanding. Phenomenography provides a way to investigate these differences to facilitate improved learning and understanding.
We suggest that a phenomenographic approach can be used to explore a number of medical education research issues, as well as more solidly linking research with educational development and change.
Recognizing the different ways in which a phenomenon is understood by different groups or within a group (of eg. clinicians, patients or teachers) can have an important impact on for example patient communication and education, inter-professional collaboration, clinical practice, theory and health care education.
Marton F. Phenomenography-a research approach to investigating different understandings of reality. Journal of Thought. 1986;21(3):28-49.
This is one of the first texts where phenomenography is described.
Marton F, Booth S. Learning and awareness. New York: Erlbaum; 1998.
This book describes phenomenography in depth.
Stenfors-Hayes, T., Hult, H. and Dahlgren, M. A. (2013), A phenomenographic approach to research in medical education. Medical Education, 47: 261–270.
In this paper, examples are provided on current studies using a phenomenographic approach, the paper also includes further details on how to conduct a study using the approach.