2012; 34: 850–861

WEB PAPER
AMEE GUIDE

Grounded theory in medical education

research: AMEE Guide No. 70
CHRISTOPHER J. WATLING & LORELEI LINGARD
Western University, Canada

Abstract
Qualitative research in general and the grounded theory approach in particular, have become increasingly prominent in medical
education research in recent years. In this Guide, we first provide a historical perspective on the origin and evolution of grounded
theory. We then outline the principles underlying the grounded theory approach and the procedures for doing a grounded theory
study, illustrating these elements with real examples. Next, we address key critiques of grounded theory, which continue to shape
how the method is perceived and used. Finally, pitfalls and controversies in grounded theory research are examined to provide a
balanced view of both the potential and the challenges of this approach. This Guide aims to assist researchers new to grounded
theory to approach their studies in a disciplined and rigorous fashion, to challenge experienced researchers to reflect on their
assumptions, and to arm readers of medical education research with an approach to critically appraising the quality of grounded
theory studies.

Introduction Practice points

The last several years have witnessed a gradual increase in the . Grounded theory has emerged from its origins in 1960s
use and acceptance of qualitative methods of inquiry in sociology to take an important place in medical educa-
medical education research. This trend reflects a growing tion research.
recognition that some of the most pressing, relevant, and . The grounded theory method is appropriate for explor-
important questions in the field cannot be satisfactorily atory research, especially that which explores social
explored using the experimental and quantitative research processes. Its intent is the development of a theory,
methods that have traditionally dominated the biomedical ‘‘grounded’’ in the data, which enables understanding of
domain. Among the multitude of qualitative methods available the process under study.
to the researcher, grounded theory has been the . Fundamental elements of the grounded theory approach
approach most frequently used in both the biomedical and include an iterative process, theoretical sampling, and
social science realms (Harris 2003). With the increasing data analysis using the method of constant comparison.
prominence of the grounded theory method in medical . Constructivist critiques of a fundamental notion of
education research, it has become necessary for researchers grounded theory - that theory can ‘‘emerge’’ from
and readers alike to have a clear grasp of its potential, its data – have led to a reimagining of grounded theory
principles, and its pitfalls. where the roles of the researcher and the research
In this Guide, we will offer first an important historical participants in knowledge construction are
perspective on the origin and evolution of grounded theory. acknowledged.
We will then elaborate the key tenets of the grounded theory . Researchers should reflect on the important critiques of
method – the elements that need to be present in order for a and controversies around grounded theory to facilitate
study to call itself a grounded theory study. Although these making appropriate analytic choices.
historical and procedural aspects of grounded theory have
been well described by others (Kennedy & Lingard 2006), a and potential pitfalls that will face researchers. The grounded
guide to grounded theory must begin here, in order to theory method, and indeed the discourse around knowledge
adequately equip readers with the background they will generation, has evolved significantly over the forty-five years
require to do, or to critically evaluate, grounded theory since grounded theory was first described. An evolving
research. This Guide will then build on previous literature on method deserves a periodic revisiting of its strengths and
the use of the method in medical education research by vulnerabilities so that it can be utilized thoughtfully and for
examining important critiques that have been aimed at maximum impact by researchers, and this Guide aims to serve
grounded theory and exploring some of the controversies this purpose.

Correspondence: Christopher J. Watling, Associate Dean, Postgraduate Medical Education, Schulich School of Medicine and Dentistry, Medical
Sciences Building Room M103, Western University, London, Ontario N6A 5C1, Canada. Tel: 519-661-2019; fax: 519-850-2492;
email: chris.watling@schulich.uwo.ca

850 ISSN 0142–159X print/ISSN 1466–187X online/12/100850–12 ! 2012 Informa UK Ltd.

DOI: 10.3109/0142159X.2012.704439
 Grounded Theory in Medical Education Research

An historical perspective critically as ‘‘only imperfectly and probabilistically apprehend-

able’’ (Guba & Lincoln 2005, p.193), but in fact the differences
Grounded theory remains inextricably linked with its sociol- between positivism and post-positivism in terms of their
ogist founders, Barney Glaser and Anselm Strauss, who influences on the approach to research questions are minor.
described, in their 1967 book The Discovery of Grounded The positivist thinking is apparent in the prominent use of the
Theory, a method for generating theory from empirical data word ‘‘discovery’’ in the original description of the grounded
(Glaser & Strauss 1967). Although they noted that the method theory method; the implication is that truth is waiting to be
could be applied to both qualitative and quantitative data, ‘‘discovered’’ by the researcher.
even suggesting that the distinction between the two types of
data was meaningless as far as theory generation was
concerned, their own research was qualitative. Even critics of New paradigms
grounded theory acknowledge that their pioneering work was The decades that followed the original description of
a key influence on the legitimization of qualitative research grounded theory witnessed extensive critiques of the positivist
methods within the social sciences (Thomas & James 2006). assumptions underlying research and the emergence of new
A perspective on the context of the times in which paradigms, including constructivism. The constructivist para-
grounded theory was developed is useful. Glaser and Strauss digm views knowledge as actively constructed and co-created
lamented the strong trend toward theory verification within the as the product of human interactions and relationships. Data
social sciences over the preceding decades, and wanted to and analysis are therefore created from ‘‘shared experiences
promote the generation of theory from data rather than the use and relationships with participants and other sources of data’’
of research exclusively to test and verify existing theories (Charmaz 2006, p. 130). Within the constructivist paradigm, the
(Glaser & Strauss 1967). In addition, although qualitative goals of research shift from the positivist goal of discovering
research had previously been well-regarded, by the 1960s, truth toward the development of understanding and adequate
quantitative scholars had relegated qualitative research to models for specific, situated purposes (Bryant 2002).
subordinate status (Denzin & Lincoln 2005). Glaser and Strauss Constructivists acknowledge the interpretive nature of theory
aimed to legitimize qualitative research in a field increasingly generation. They are reflexive about the role of the researcher
dominated by quantitative approaches by clarifying and in creating these interpretations and reject positivist notions of
codifying their procedures and practices for data analysis. In the researcher as dispassionate analyst (Charmaz 2005). The
short, they were interested not only in advancing social research process is viewed as one of active engagement,
science research but also in advancing a political agenda by where the researcher brings his or her own background and
demonstrating that qualitative research could attain levels of assumptions to the analytic process.
rigour that would allow it to stand alongside well-accepted The influence of postmodern notions of knowledge
quantitative methods of inquiry (Bryant 2002). production has led to further calls to updating the grounded
An examination of Glaser and Strauss’s ideas about theory method. In stark contrast to positivism, with its goal of
‘‘theory’’ and its discovery is enlightening. Their key notion uncovering basic social processes that are simple and gener-
that theory emerges from empirical data, and is thus alizable, postmodernism acknowledges and emphasizes com-
‘‘grounded’’ in data, remains an important principle guiding plexity, instability, and heterogeneity (Clarke 2003). Clarke
much grounded theory work today, even as the idea of contends that grounded theory and other qualitative
emergence has been disputed and critiqued (Bryant 2002, approaches are no longer acceptable without the reflexivity
2003; Kelle 2005). They distinguished between substantive and explicit acknowledgment of complexity that postmodern-
theories, based on empirical areas of inquiry within a particular ism demands. She has advocated for a more sweeping
domain, and formal theories, which were conceptual, distinct overhaul of the grounded theory method through the incor-
from the time and place of specific settings and social poration of newer approaches, such as situational mapping,
structures. Substantive theories, they argued, could and that are more compatible with postmodern sensibilities (Clarke
should be generated from the researcher’s own data (Glaser 2003).
& Strauss 1967). While they called for grounding of even
formal theories in data rather than ‘‘borrowing the ways of
logico-deductive theorists’’ (Glaser & Strauss 1967, p.91), Doing grounded theory research:
they acknowledged that formal theory could not easily be Principles and procedures
derived from the researcher’s own data, unless a large number Although grounded theory has evolved as a result of this
of studies in a variety of substantive areas had been done. critical questioning of its underlying assumptions, there remain
a number of fundamental methodologic strategies that define
grounded theory studies. These metholodologic fundamentals,
Positivism
including an iterative process, systematic treatment of data
In its original form, grounded theory was rooted in objectivist through coding, constant comparisons, and theoretical sam-
and positivist assumptions. The positivist paradigm assumes a pling, will be discussed in the next section. We will illustrate
true reality that is apprehendable by a detached, objective these principles and procedures, where useful, by making
researcher (Guba & Lincoln 2005). Glaser and Strauss’s original reference to a recent grounded theory study of our own
work, in fact, occurred at a time when a post-positivist (the ‘‘influential experiences study’’) in which we
paradigm was emerging, in which reality is viewed more explored the important influences on physicians’ learning
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(Watling et al. 2012). We will start, however, where every of that phenomenon to reduce it to its essence (Cresswell
piece of research should start – with a strong research 2007). Central to phenomenology is the practice of bracketing,
question. in which the researcher identifies preconceptions, supposi-
tions, and biases that may influence data interpretation, then
attempts to deliberately set these biases aside (Dornan et al.
Research questions in grounded theory studies 2005). In the case study approach, the researcher chooses to
Unlike the experimental approach to research that dominates study a case or a small number of cases whose boundaries can
biomedical disciplines, grounded theory research is not about be readily defined (Stake 2005). Case study research is defined
testing hypotheses. Rather, grounded theory research is by what is studied rather than by how it is studied, and
exploratory, seeking to understand the core social or social typically involves the collection and analysis of information
psychological processes underlying phenomena of interest. from multiple sources. Its goal is an in-depth understanding of
Grounded theory allows the researcher ‘‘to explicate what is the complexity of an individual case, rather than the derivation
going on or what is happening . . . within a setting or around a of theory or the elaboration of generalizable principles
particular event.’’ (Morse 2009, p.14) These aims determine (Cresswell 2007).
the types of research questions that should be asked in a Of course, a myriad of other qualitative approaches also
grounded theory study. The questions should be broad exist to explore social phenemona, such as auto-ethnography,
enough to allow the researcher the freedom to explore a hermeneutics, and critical discourse analysis. While it is
topic in depth, while not being entirely unfocused (Corbin & outside the scope of this Guide to review all possible
Strauss 2008). The initial research questions should define the approaches with regards to the question of how a researcher
scope of the study and guide the collection of data, while determines whether grounded theory is the best methodolog-
allowing flexibility for the researcher to follow the sometimes ical fit, we would encourage researchers to take seriously this
unexpected turns that arise as data is examined. For example, step of the research process by informing themselves of the
in our ‘‘influential experiences study’’, we were interested in most relevant methodological options and weighing their
exploring the qualities of those clinical experiences that relative strengths and weaknesses for grappling with a
meaningfully influenced physicians’ learning1. In the inter- particular research question.
views we employed for data collection, we asked what kinds Once the researcher has crafted a compelling research
of experiences physicians considered most influential in their question, considered the methodologic options, and deter-
learning, and what allowed these experiences to resonate with mined that grounded theory is an appropriate approach,
them (Watling et al. 2012). These questions were sufficiently concern can shift to the procedural elements that define the
broad to allow us to collect data that elucidated the experience conduct of a grounded theory study, which we describe
of clinical learning in some depth, while still allowing us to below.
define the contexts and individuals of interest.

Iterative process
Ensuring methodologic fit In The Discovery of Grounded Theory, Glaser and Strauss
The researcher may benefit, at this stage, from pausing to highlighted the iterative nature of the grounded theory
ensure that the grounded theory method is an appropriate fit method, noting that collection, coding, and analysis of data
for exploring the research questions at hand. Qualitative should ‘‘blur and intertwine continually’’ (Glaser & Strauss
researchers have a number of approaches from which to 1967, p.43). In contrast to most experimental, hypothesis-
choose. In addition to grounded theory, some common driven quantitative research, in which data collection is
approaches include ethnography, phenomenology, and case carefully controlled and deliberately not influenced by emerg-
study. An appreciation of the key features of each of these ing results, grounded theory research involves performing data
alternative approaches will assist the researcher in choosing collection and data analysis simultaneously, with each inform-
wisely. ing the other. In an interview study, for example, an iterative
Although there may be some overlap between the various process means reading transcripts as they are completed and
approaches to qualitative inquiry, they have, at their core, allowing early analytic insights and conceptual ideas to shape
distinctly different goals, and as a result they lead to distinctly subsequent data collection. Findings that were unanticipated
different products. Ethnographic research uses the concept of or that may represent a compelling area for further exploration
culture as a lens through which to interpret data (Goodson & are followed up in subsequent interviews with directed
Vassar 2011). The ethnographer aims to understand a social probes. In turn, the additional information gained by directing
organization from within, and typically relies heavily on the inquiry toward emerging areas shapes the ongoing
observations as a data source, often obtained through analysis.
sustained immersive engagement in a social milieu (Atkinson
& Pugsley 2005). The product of ethnographic research, an
Coding
ethnography, provides a ‘‘holistic cultural portrait’’ of the
studied group. (Cresswell 2007, p. 72). Phenomenology, in Coding is a key part of the analytic strategy in grounded theory
contrast, focuses on describing the meaning of an experienced studies. Through coding, data are organized around key
concept or phenomenon. The research starts with a phenom- conceptual areas or themes. As a result, coding done well
enon of interest, then studies several individuals’ experiences requires more than merely describing or summarizing the
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contents of the data. Rather, coding requires the researcher to Box 1. Coding scheme for ‘‘Influential Experiences Study’’.
interact with their data in order to make sense of it. Coding is
therefore an intrinsic and essential part of the process of theory 1. Feedback credibility
! The process of deciding what feedback/information can be trusted
building. ! Deciding how much weight to place on feedback
There are multiple approaches to coding data that have ! Influence of the source/sender of the feedback on its credibility
! Which sources of feedback are respected? What earns them
been described in detail elsewhere (Charmaz 2006; Corbin & respect?
Strauss 2008). During initial coding, it is important that the ! Alignment of feedback with self-assessment
2. Influence of feedback
researcher remains open to many possible conceptual and
! When is feedback influential/neutral/non-influential/counter-
theoretical directions (Charmaz 2006). Focusing the initial productive?
coding phase on small units of analysis, such as individual ! Comments related to the influence of negative feedback and the
influence of positive feedback
lines or sentences within transcripts, ensures that the most ! Comments about barriers to the creation or delivery of useful
salient ideas are identified and given appropriate attention. feedback
! Influence of style of feedback delivery on whether it is influential
From this initial detailed mining of data comes a second coding ! Influence of context on receptivity to feedback
phase where broader categories are developed that may 3. Learning by observation
! Observation and attempted emulation as an approach to learning
encompass a number of conceptually related ideas. ! What is being observed? ( physician behaviour, patient response,
Frequently, the coding scheme will evolve as further data are one’s own comfort . . .)
! Comments about ‘‘negative’’ role modeling (learning how not to do
collected. Certain categories will be absorbed by others as it things)
becomes clear that their data are related by particular unifying 4. Learner attitude
! What the learner brings to the table and its influence on learning
features, while other categories will split as distinct sub- ! Taking initiative . . . to seek out feedback, learning experiences, etc.
concepts emerge in the process of examining fresh data. ! Openness to learning
! Motivation for learning – e.g. Wanting to be good at the job, wanting
A more detailed coding example may be instructive at this to look competent
stage. In Box 1, we show an early coding scheme that evolved 5. Measuring up
! Wanting to measure up to peers
as interview data were analyzed in our ‘‘influential experiences ! Wanting to please supervisors, meet their expectations, earn their
study’’. The coding scheme shown in Box 1 was developed respect
! Not wanting to disappoint/fail
after reading and re-reading the first 15 of what would ! The effects of the threat of being humbled in front of peers or
ultimately turn out to be 22 interview transcripts. Note that colleagues on learning
6. Confidence
each proposed code is followed by a series of descriptors that ! Influences on the development of confidence and/or self-doubt
define its characteristics and its limits. This strategy provides ! Comments relating to the development of professional identity
! Learning to trust judgment and instincts
important guidance to the researcher as the task of categoriz- ! Fragility of confidence
ing data is approached. ! Interaction between confidence and receptivity to feedback
7. Learning from the work
! Memorable clinical or work experiences
! Emotional impact of memorable clinical experiences
Constant comparison ! Value of supervised teaching vs. simply accumulating clinical
experience
As coding proceeds, the analytic process enacted is one of ! Role of supervisors in debriefing work incidents and the effect of this
input
constant comparison. As the data are examined, incidents are ! Clinical outcomes/results as a form of feedback on performance
compared with other incidents and with the emerging char- ! Limitations of learning from the work – i.e. When is the ‘feedback’
offered by the clinical work itself less than trustworthy?
acteristics and properties of the category (Glaser & Strauss ! ‘‘Growth moments’’ that signal readiness to move to the next level
1967; Corbin & Strauss 2008). The comparative process defines 8. Self-assessment
! Perceived role and importance of self-assessment during training
the breadth and characteristics of each category, and facilitates ! Perceived accuracy of self-assessment
the emergence of new categories when incidents are encoun- ! Influences on self-assessment – how it is informed or constructed
9. Independence/autonomy
tered that illustrate new concepts. Counter-examples – the ! Experiences of independence, autonomy, or ‘‘freedom’’ during
‘‘negative cases’’ that are encountered – are particularly training
! Being given trust or autonomy as a form of positive feedback (e.g.
important within the constant comparative process. Indeed, comments about a supervisor deciding not to come in to review a
such outliers can unlock vital analytic insights that contribute case personally, or about being allowed to do a procedure)
! Taking responsibility for clinical cases and its effect on learning
to theory development. In comparing these incidents with the 10. Collegiality
existing properties of the category, the researcher is forced to ! Being included or ‘‘let in’’
! The value of ‘‘support’’ (vs. supervision, teaching, etc)
think beyond simple categorizations of like with like, revealing ! Rites of passage (e.g. ‘‘surviving’’ critical feedback as a rite of
in the process conceptual principles that can account for the passage)
! Support of peers; camaraderie
full range of data that is encountered. 11. Assessments
! Influence of assessment strategies (including OSCE, ITER, final
exams) on learning and development during training
! Influence ( positive or negative) of looming certifying exams on
From codes to concepts learning
12. Role models
Coding is not an end in itself; rather, it is a strategy to facilitate ! Comments related to individuals viewed as role models
theory development. The strategy only succeeds when its ! What enables someone to become a role model?
! Ideas about the influence of role models
power is harnessed, and doing so requires that the researcher 13. Mentoring
not be satisfied with mere thematic classification. The analysis ! Comments related to mentoring (either explicitly labeled as such or
not)
must be raised from the categorical to the conceptual in order ! Comments related to individuals offering advice, guiding career
to generate theory. Analysis at the conceptual level requires decisions, offering opportunities that were important
asking questions of the data: What is happening here? What is
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this incident an example of? Why are participants reacting this categories for this study reflects a move toward conceptual-
way? Such efforts to define the underlying story within the data izing our data rather than simply categorizing it (Box 2). For
are rewarded with a richer analytic product. One approach to example, the previous categories of ‘‘learner attitude’’ and
deeper, conceptual analysis involves exploring the relation- ‘‘independence/autonomy’’ were conceptualized as elements
ships among the major categories that emerge from the coding of ‘‘learning conditions’’, while ‘‘measuring up’’, ‘‘formal
process. The ideas that link categories can provide the assessments’’, and ‘‘role models’’ were conceptualized as
conceptual scaffold to support theory development. elements of ‘‘learning cues’’. Although ‘‘feedback’’ was also a
Returning to our example, the coding scheme evolved and learning cue, we felt this category was so significant that we
was refined as further data were analyzed, as the links opted to keep it distinct to ensure that its richness was not lost
between categories were explored, and as we asked not only in the analysis.
what was said but what was meant. The final list of coding

Facilitating analysis with memos and diagrams

Box 2. Final coding scheme for ‘‘Influential Experiences Memos are a written record of analysis (Charmaz 2006; Corbin
Study’’.
& Strauss 2008). Grounded theory researchers should write
memos regularly as they collect and analyze their data.
1. Learning by doing/ learning from clinical work
2. Learning conditions
Although memo writing can serve as an intermediate step
a. Autonomy between collecting data and drafting a manuscript for publi-
b. Collegiality cation, the process should be free and informal. Researchers
c. Influential teachers
d. Learner attitude
should record the ideas that occur to them as they move
e. Presence of mentors through the process of exploring their accumulating data.
3. Learning cues Memo-writing facilitates the emergence of new insights
a. Being allowed to do things vs. requiring supervision
b. Feeling comfortable with tasks and the elaboration of relationships among categories, pro-
c. Formal assessments of knowledge and skill pelling the analytic process forward. The act of writing a memo
d. Measuring up (to peers, to standards, to expectations) forces the researcher to examine coded data and to interpret its
e. Responses of patients and families
f. Patient or clinical outcomes meaning at a conceptual level. A collection of memos
g. Role models signposts the development of a grounded theory, ensuring
4. Determining credibility (i.e. of learning cues and experiences)
that the process is logical, systematic, and grounded in
5. Receiving feedback
a. Influence of feedback in general the data.
b. Debriefing difficult experiences Box 3 contains an extract of a memo written during the
c. Preceptors’ responses to learner errors
analysis of data collected for the ‘‘influential experiences
6. Learning outcomes
a. Confidence study’’ example. As the data was examined, we noted
b. Practice change recurring references to the credibility of information that was
c. Fragility of learning from clinical experience
available to learners related to their own performance, and we
7. Reflection
became interested in how learners determined what informa-
tion was credible and what was not, particularly as it related to

Box 3. Memo on ‘‘Determining credibility’’.

1. Learners consider a number of factors when making judgments about the credibility of the learning information that surrounds them. These factors include
whether or not the information aligns with their personal values. If it conflicts with their personal and professional values, it is likely to be judged as not
credible and discarded.
2. Credibility of feedback received from a supervisor is strongly linked to the respect the learner has for the supervisor. Respect is derived largely from that
individual’s performance as a clinician, rather than his or her style of relating to the learner. The degree of esteem in which the supervisor is held within the
community may factor into the decision-making process, and learners may use informal networks of colleagues to determine this. Learners also use their
own observations of the clinical performance of their supervisors to guide their credibility judgments.
3. As they become more experienced themselves, they are able to make more sophisticated judgments. Reputation alone is not a guarantee of credibility.
4. Linked with #2 above, those supervisors who achieve role model status tend to have credibility, again based on their perceived clinical expertise.
5. When feedback from a supervisor is clearly linked to the clinical work, and when the central concern is patient well-being, the feedback is deemed credible
(regardless of how it is delivered)
6. Feedback that matches self-assessment is more likely to be deemed credible.
7. Feedback credibility is strengthened when sound rationale or justification accompanies it. The most persuasive rationale is grounded in clinical work and
outcomes. Feedback needs to ‘‘make sense’’ in the clinical context.
8. Feedback from patients or families is more likely to be judged as credible.
9. Negative feedback can be judged as credible when accompanied by clear evidence that it is true. Perhaps this evidence is a requirement? In a sense, it is
necessary for the learner to decide to agree with the feedback.
10. Feedback deemed not credible may have unintended consequences. (e.g. Feedback is dismissed, learner career choice is affected, etc)
Some general comments:
Credibility statements mainly relate to determining the credibility of feedback. Does this imply that other performance indicators (e.g. Clinical outcomes) have
intrinsic trustworthiness?
The judgments that are made are grounded in the clinical work – Is the feedback source good at the work? Does the feedback align with the learner’s value
system and their approach to their professional work?

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Box 4. Example of diagram drawn from data collected.

Learning
environment
• Collegiality
• Mentors
Information
Explicit Feedback Used

Reflection
Clinical Work
CREDIBILITY Judgment Outcomes

Self-assessment

Information about Information

performance Dismissed

• Role models
• Standards

feedback received from their supervisors. In this memo, They promote organization of concepts, understanding of
written after careful examination of the data contained in the relationships among concepts, and reduction of data to its
‘‘determining credibility’’ category of the final coding scheme essence (Corbin & Strauss 2008). Building on the same
shown in Box 2, key insights emerging from the data on this example, our ability to relate our key concepts to one another
issue are outlined. Note that the writing is free and stylistically in a unified model of clinical learning was very much facilitated
crude; the attention is on the ideas themselves rather than on by the use of diagrams. Consistent with the iterative nature of
grammar and syntax. Questions raised in the analytic process grounded theory research, our diagrams evolved through
are articulated in the memo to signal potentially important multiple incarnations, both reflecting and driving our concep-
ideas requiring further thought and attention. tual thinking. Box 4 shows an example of one such diagram;
Ultimately, we recognized that learners’ judgments about interested readers may wish to compare this early diagram with
the credibility of feedback and other information about their the final version that was included in our published manuscript
performance played a pivotal role in their clinical learning. (Watling et al. 2012).
Memos such as this one facilitated our recognition of the
richness and centrality of this idea. Analysis is strengthened
when memos are treated iteratively; they should be revisited Inspiration and creativity
and revised as data collection and analysis proceeds. It is Grounded theory seeks to derive conceptual understanding of a
worth noting that in the original, lengthier version the memo process by carefully examining the elements and categories
shown in Box 3, each listed point was supported by 2-3 related to that process emerging from the data collected. Just
quotations directly drawn from the data. Although direct how categories become concepts and description becomes
quotations need not appear in memos, the exercise of inserting understanding can seem mysterious and difficult to grasp.
them into the original memo on determining credibility served Creative thinking is an inescapable element of grounded theory
not only to ensure that the insights were grounded in the data research, which requires interpretation rather than mere
but also to facilitate the writing of the manuscript later. description. Interpretive inspiration, however, is not accidental.
Diagrams can serve a similar purpose to memos in grounded The researcher must deliberately create the conditions that will
theory work. Diagrams are visual representations of the facilitate the emergence of meaningful interpretive insights.
relationships between concepts that emerge. The creation of a Maintaining a flexible coding system that is responsive to the
diagram requires the researcher to raise their thinking about the data, engaging in regular memo writing, and using diagrams
data from the level of categories to the level of concepts, to help bring ideas together into a coherent story are all
adding value to the analysis (Corbin & Strauss 2008). deliberate strategies for facilitating the interpretive process.
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Ultimately, however, the key facilitator of interpretation is a address the research question. As a result, sample size in
thorough knowledge of the data. Only by examining and re- qualitative research in general can be a thorny issue for both
examining data in detail will the researcher be able to recognize novice researchers and for institutional review boards and
the patterns and recurring themes that will guide the analytic granting agencies, particularly those from fields where the
process. quantitative, experimental approach to research is dominant.
Morse (1995) has offered a number of useful guidelines for
addressing problem of saturation. Perhaps most important, she
Theoretical sampling calls for thoughtful and theoretical justification of the sample,
The sampling strategy in grounded theory research is purpo- noting that saturation will occur more readily with theoretical
sive and guided by theoretical considerations. Initial sampling sampling than with convenience or random sampling. She also
is guided by the research question. The researcher purpose- emphasizes data richness and variation over data quantity. As
fully selects sources of data that are considered likely to we have emphasized above, careful attention given to the
provide rich information relevant to these questions. As infrequently occurring outliers and negative cases may be
Charmaz points out, this initial sampling provides only ‘‘a much more productive in achieving saturation than collecting
point of departure’’ (Charmaz 2006, p.100); subsequent a large number of like cases, as it is the examination of these
theoretical sampling is guided by the categories and concepts infrequent cases that can facilitate delineation of concepts,
that emerge from this initial data collection. linking of concepts, and development of theory. In short, data
Theoretical sampling entails the collection of data ‘‘from collection can stop when a complete and convincing theory
people, places, and events that will maximize opportunities to has been developed that provides a plausible account of the
develop concepts in terms of their properties and dimensions, data without gaps or leaps of logic (Morse 1995).
uncover variations, and identify relationships between con-
cepts’’ (Strauss & Corbin 2008, p.143). Unlike sampling
strategies used in hypothesis-driven experimental research,
Critiques of grounded theory
theoretical sampling is responsive to the data rather than The grounded theory method has been criticized on a number
established before the research begins (Strauss & Corbin of fronts. A brief overview of some of the key critiques is
2008). Theoretical sampling can therefore only occur in the relevant both for researchers using the method and for readers
context of an iterative process in which data analysis not only of grounded theory studies. Researchers will benefit from an
occurs concurrent with data collection, but actually drives data awareness of these critiques, both in the design of their studies
collection. The researcher explicitly seeks out new sources of and in how they position their work. Educators reading
data that facilitate developing and refining theoretical con- grounded theory research will benefit from the critical eye
structs. The goal of theoretical sampling is not to ensure that afforded them by a familiarity with some of the reservations
the sample is representative of a population nor to allow about the method that have been articulated.
statistical generalizability of the results; rather, the aim is
to ensure rich and full theoretical development through
strategic and specific sampling to elaborate and refine cate- Critiques from the interpretivists
gories and concepts (Charmaz 2006). Theoretical sampling The strongest critiques of grounded theory target its failure to
allows the researcher to confirm, refute, expand, and refine shake off its positivist origins and to reimagine and realign
developing ideas. itself as new ways of thinking about knowledge and its
generation have emerged (Bryant 2002). To those who
embrace the constructivist paradigm, the notion of ‘‘emer-
Saturation
gence’’ of theory from data is especially problematic. How
How does the researcher know when enough data has been does theory, in fact, emerge from data? Classic grounded
collected? The guiding principle is to continue sampling until theorists call for the researcher to enter the field with ‘‘abstract
saturation has been reached, but saturation refers to more than wonderment’’ (Glaser 1992, p. 22), and emphasize the
a state where no new data are emerging. Saturation is ‘‘informed detachment’’ of the researcher (Glaser & Strauss
intimately linked with the analytic process, and can only be 1967). The researcher, freed from the shackles of prior
determined within an iterative process of data collection and knowledge or personal perspectives, can then ‘‘discover’’ the
data analysis. Saturation must be viewed at a conceptual and truth within their data. Constructivists argue that these ideas
theoretical level, rather than at a data level. The important about the passive stance of the researcher toward their data
questions to ask in determining saturation relate to whether and the emergence of theory are simply not tenable within
sufficient data has been collected for the researcher to have postmodern paradigms (Bryant 2002). Fish (1994) speaks
gained an adequate understanding of the dimensions and colourfully about the zaniness of putting aside personal beliefs
properties of the concepts and themes that have emerged. and perspectives for purposes of doing grounded theory
The notion of saturation is challenging because the research, and this comment reflects a key constructivist
determination that it has been reached rests on the judgment critique of grounded theory: that it fails to acknowledge the
and experience of the researcher. Unlike in the quantitative researcher’s key role in constructing and creating knowledge
methods familiar in biomedical research, there are no guide- through interaction with the participants and with the data.
lines or formulae available to grounded theory researchers for Some grounded theorists have responded to these critiques
estimating the sample size that will be required to adequately by emphasizing the importance of researcher reflexivity in the
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analytic process. Deliberate reflection provides perspective on spirit of reflexivity that is inherent in the constructivist
the researcher’s influence on the research process, making approach to grounded theory, we acknowledge our own
clearer his or her own contribution to the construction of position as constructivist qualitative researchers. In order to
knowledge. What the researcher should do with the insights remain relevant we believe that grounded theory must evolve
gained from reflection is the subject of debate. Corbin and to incorporate constructivist notions of knowledge creation. To
Strauss, for example, display hints of constructivism in us, the idea that the researcher can set aside his or her own
enshrining reflexivity as essential to the grounded theory background knowledge, experience, and theoretical leanings
process, but imply that the value of reflexivity is, in part, in on entering the research field and play the role of passive,
providing a safeguard against the intrusion of personal bias objective observer seems outdated and implausible.
into the analysis (Corbin & Strauss 2008). This notion that the On the other hand, we believe there is much value in the
researcher must recognize and then deliberately temper his or principles grounded theory provides for approaching explor-
her perspective as they approach the task of theory-building atory, qualitative research. Methodologic evolution based on
has been criticized as still firmly reflective of a positivist reconsideration of underlying assumptions about knowledge
tradition, as it suggests that there is a truth within the data that and the role of the researcher in its elaboration does not mean
can only be revealed if the researcher remains somehow that these useful principles should be abandoned. As Babchuk
outside of it. (1997) has noted, grounded theory has been used as an
Those speaking from a more firmly constructivist or umbrella term for a wide variety of styles and approaches to
interpretivist position ask why this kind of interpretive distance qualitative data analysis across a range of literatures; this
is useful. Constructivist grounded theory retains the emphasis ‘‘anything goes’’ approach is surely harmful to the credibility
on an iterative approach to analyzing and conceptualizing and relevance of grounded theory research. We therefore
data, but redefines the ultimate theory-construction goal to aim advocate for an informed use of grounded theory, combining
for ‘‘interpretive understanding and situated knowledge’’ respect for the rigour provided by maintaining its core tenets
(Charmaz 2008, p.133). Constructivist grounded theory stresses with recognition that the positivist assumptions on which the
reflexivity, acknowledging the roles of the researcher, the method was built require rethinking in view of constructivist
research participants, and the research situation and process in conceptions of knowledge creation. Grounded theory
knowledge construction (Charmaz 2008). Given the shift in researchers can help readers to use their work in an informed
fundamental assumptions about knowledge creation that way by being explicit about their paradigmatic allegiances,
underlie constructivist grounded theory, some interpretivists their background, their role in data collection, and their
have questioned why the term ‘grounded theory’ is retained at relationship to their subjects or to their field of study.
all by those who undertake qualitative research in the
constructivist paradigm (Thomas & James 2006).
Pitfalls in grounded theory research
Critiques from the classicists
Not taking the interpretive process far enough
Led by Barney Glaser, adherents to classical grounded theory
have criticized the constructivist modification of grounded Not all grounded theory studies can generate bold, enlighten-
theory for its failure to maintain some of the important ing new theories. However, some studies seem content not to
principles that define the method. In particular, the issue of try, settling instead for lists of themes or concepts, rather than a
researcher bias is presented as a problem that can be resolved ‘‘big picture’’ rendering of their data (Kennedy & Lingard
by ensuring that the data is raised to a conceptual level, and by 2006). Compared with other forms of qualitative inquiry,
treating the researcher’s own experiences, if they are similar to grounded theory seems on the surface to provide a clearer
those of some of the research participants, as data to be roadmap for researchers to guide their efforts. This very
compared with other data. Glaser contends that the work of structure, however, might promote an analysis that is not fully
Charmaz and other constructivists represents legitimate quali- realized. It is relatively easy to describe a process by
tative data analysis, but not legitimate grounded theory (Glaser which data can be classified and categorized, but not at
2002). He maintains that legitimacy, in grounded theory, grows all straightforward to describe the subsequent creative ele-
out of trust in and adherence to the constant comparative ment of developing theory from these categorizations, which
approach. If, he contends, the researcher looks carefully at calls for interpretive skill and creativity. It is easy for the
multiple cases of the same phenomenon, researcher bias will be researcher to become bogged down in the apparently
eliminated and the data will be made objective. Legitimate prescriptive coding procedures and to lose sight of the larger
grounded theory, in his view, is about conceptualization, while goal. Juliet Corbin, who has described the techniques and
the constructivist modification is so focused on description and procedures of the grounded theory method in considerable
on representing the voice of its research subjects that it ceases to detail, reminds us that ‘‘the analytic process is first and
be grounded theory (Glaser 2002). foremost a thinking process’’ (Corbin 2009, p.41) that should
be driven by the insights gained through interaction with data
rather than by a need to follow specific procedures. Charmaz
Positioning ourselves
helpfully urges researchers to push the boundaries of
We view these critiques from both ends of the spectrum as their findings and answer the ‘So what?’ questions
healthy and invigorating for grounded theory research. In the (Charmaz 2006, p.107).
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C. J. Watling & L. Lingard

Making unsupportable claims of explanation from one that precedes it, the researcher’s growing familiarity
with relevant literature in the area of research is unavoidable
Legitimate questions have been raised about whether the
and in fact will facilitate the generation of compelling new
product of grounded theory studies is really ‘‘theory’’ at all
research questions that advance the program.
(Thomas & James 2006). Thomas has criticized grounded
Interestingly, even Glaser and Strauss acknowledged that
theory for promising too much; its insistence that its product is
researchers require a perspective that allows the identification
‘‘theory’’ rather than description or understanding suggests a
of relevant data and the abstraction of significant themes from
power to explain and predict that, he argues, is rarely present
that data (Glaser & Strauss 1967). Our own view is that a
(Thomas & James 2006). Indeed, grounded theorists must
literature review is indispensible in providing exactly this
guard against making unsupportable claims from their analy-
perspective and in shaping the research question. We caution
ses. Unlike Thomas and James, however, we do not believe
researchers, however, to remain deliberately open-minded
that the goal of theory generation should be abandoned, as it is
to the data and the concepts and ideas that it contains: across
this very goal that distinguishes grounded theory work from
the spectrum of grounded theorists, this initial open-minded
other forms of qualitative research. Charmaz (2006) resolves
approach to data analysis is widely endorsed (Glaser & Strauss
this issue by suggesting that grounded theory researchers look
1967; Charmaz 2006).
to interpretive definitions of theory that emphasize ‘‘imagina-
tive understanding’’ ( p. 126) rather than explanation. Similarly,
Bryant (2002) suggests targeting a constructivist goal of The integration of existing theory
achieving adequate understanding for specified contexts and
purposes, rather than a positivist goal of discovering truth or Although Glaser and Strauss cautioned researchers against
bringing preconceived notions drawn from existing formal
establishing generalizable theories with the power to explain
theories into the field (Glaser & Strauss 1967), they acknowl-
and predict.
edged that the generation of new grounded theory need not
Researchers should therefore reflect thoughtfully on the
occur in complete isolation from existing theory. Their aim was
goals of their work and the limits of their emerging theory’s
to highlight the importance of explicit efforts at open-mind-
explanatory power. Bold claims of generalizability of findings
edness, which we believe remain central to grounded theory
should be viewed with suspicion. Grounded theory might
research. Can open-mindedness co-exist with knowledge of
identify relevant relationships, key influences on a process, or
and familiarity with existing theoretical perspectives? Can
challenges facing individuals or groups, for example, but
existing theory be integrated into grounded theory research
cannot determine the magnitude of these relationships,
without ‘‘contaminating’’ the analytic process? We believe that
influences, or challenges. Making such determinations would
it can and should be integrated, but the approach to using
require an entirely different research approach, involving
existing theory remains controversial.
statistical sampling, with a distinctly different goal. Grounded
Certainly after a grounded theory emerges, it is appropriate
theory might therefore generate hypotheses that could be
to consider how existing theoretical frameworks might com-
tested using other methods, including quantitative, experi-
plement or extend the data interpretation or offer alternate
mental methods, but grounded theory is not the vehicle for
explanations for challenging data. Indeed, some have sug-
testing those hypotheses.
gested that researchers should, as a matter of course, explicitly
‘‘ground’’ the theories they derive from data in existing
Controversies in grounded theory theories, in part as a response to the criticism that grounded
theory work done in isolation from existing theories risks non-
research
cumulative theory development and thus stifles the building of
knowledge (Goldkuhl & Cronholm 2003). Even those
The literature review
researchers with positivist leanings tend to support the linking
One area where researchers will encounter variable and often of emergent grounded theories with existing theories, pro-
conflicting advice is the place of the literature review in vided that the timing of doing so is such that the very
grounded theory studies. Dunne (2011) notes that performing development of the grounded theory is not forced into a pre-
a literature review is considered appropriate by researchers at existing theoretical framework. Constructivists would argue,
all points along the spectrum of grounded theory; the however, that this notion of first allowing the grounded theory
controversy lies in the suggested timing of that review. to emerge, free of existing theoretical constraints, and then
Glaser and others, for example, argue against a significant only later integrating relevant existing theories to enrich it is
literature review in advance of data collection and analysis on artificial and impractical. To the constructivist, the researcher’s
the grounds that an early, comprehensive literature review will disciplinary background and theoretical perspective may
so burden the researcher with preconceived notions and provide vital sensitizing concepts that alert them to possibilities
theoretical baggage that his or her analytic capacity will be and processes within their data and that guide them in asking
irretrievably weakened (Glaser 1992, Nathaniel 2006). Others relevant questions (Charmaz 2006).
have noted the inefficiency of abstinence from a literature Controversy around how and when to integrate existing
review in advance, and have commented on the potential for theory in grounded theory research creates challenges not
the literature review to enrich the research by sharpening the only for researchers but also for those who will read and
focus and improving the research questions (Dunne 2011). In review their work. Researchers using grounded theory need to
programmatic research, where one study follows logically be skillful in their descriptions of their research methods in
858
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manuscripts they submit for publication, anticipating and perspective influences their analysis and their theory
addressing potential critiques based on their use of existing construction.
theory. A clear description of a careful and methodical coding We have found that working collaboratively can enhance
process in which codes and categories emerge from the data the analytic process significantly. The entire process need not
rather than being imposed on the data will reassure readers be a group effort, but there are key points in the course of the
and reviewers that the researcher has been open-minded in research where strategic use of collaborators can be highly
their initial approach to their data. Furthermore, researchers productive and illuminating. During the phase of initial coding,
should make the case for the logic of drawing on existing it can be helpful to have two or three researchers examine the
theories; the use of existing theory must ‘‘make sense’’ in the same data independently and code the data for the themes that
context of the data analysis that is presented. they perceive as emerging from it. As collaborators meet to
discuss their initial impressions of the data and the codes they
have devised, a more robust coding scheme can emerge as
Computer-assisted data analysis
disagreements are aired and consensus is reached. The
Qualitative data analysis of any type can be daunting, as process of constant comparison is thus expanded to include
researchers often face the challenge of managing mountains of comparisons not only among the data but among different
data. Increasingly, computer software programs are being used perceptions and readings of the data. Collaboration may also
by grounded theorists and other qualitative researchers to be valuable after the initial coding is complete, at the critical
facilitate the process of data analysis. These programs offer stage where the researcher needs to raise the interpretive level
many potential advantages to the researcher. Software pack- from the concrete to the abstract – from categories to concepts.
ages can allow organization of data into coding categories and We often bring in collaborators at this stage to discuss the
subcategories, can identify links between categories, and can elements of one or more categories at an interpretive level.
link categories to memos and other relevant documents. This These discussions invariably assist in raising the analytic
organizational system is readily searchable, allowing efficient thinking to a conceptual level, as the why, how, and so what of
data management and ensuring that gems within the data are the processes identified within the data are examined from
readily found when the researcher needs to support core different perspectives. Collaborative discussions of emerging
concepts as they write up or present their analysis. The use of concepts can also provide the researcher with a useful
data analysis software also can provide an audit trail that tracks perspective on how these concepts might resonate with their
the analytic steps that were taken. target audience, or on which concepts are the most central or
Computer assisted data analysis is not a substitute for a compelling in the overall story of the research.
rigorous method of data analysis, and studies purporting to use Collaboration is not a substitute for reflexivity for the
grounded theory whose methods are described in terms such grounded theorist. However, deliberate collaboration with
as ‘‘Data were analyzed using N-Vivo’’ should be viewed with colleagues with distinctly different perspectives can help to
suspicion (Jones & Diment 2010). It is grounded theory, and ensure a balanced rendering of the data in the analytic process.
not the software package, that provides the principles that Colleagues from different backgrounds can push the researcher
guide the data analysis. The computer is merely a tool that can to think beyond their own disciplinary box, or rein in the
support the researcher in being both thorough and efficient in researcher who needs reminding to ground their theory devel-
the analysis. The researcher still must interpret the data, opment firmly in the data rather than allowing that theory to
recognize emerging concepts, ask how concepts and catego- be shaped primarily by their own background and perspective.
ries relate to one another, and push the analysis to an abstract
level that promotes theory development. The creativity
Quality criteria for grounded theory research
required of the researcher in developing theory cannot be
provided by a computer (Becker 1993). However, software Although the procedures for carrying out grounded theory
packages can provide opportunities for researchers to explore research are highly structured, the criteria on which the quality
their data visually in a variety of ways, which when used of a grounded theory study should be evaluated are less clear.
strategically may foster creative thinking and stimulate the Relative to the quantitative research strategies that dominate
emergence of insights that enhance the analytic process biomedical research, where researchers and readers alike can
(Bringer et al. 2006). refer to clear guidelines for appraising the quality of a piece of
research, the criteria for judging grounded theory work can
seem vague and challenging to interpret. Nonetheless, a
Solo analysis versus collaborative analysis
number of authors have suggested criteria for evaluating
Much grounded theory work is described as if the analysis is grounded theory studies, and a brief examination of some of
done entirely by a single researcher, hunched over a computer these criteria is useful.
or sifting through piles of documents on a table until some sense Glaser and Strauss, in their original description of the
can be made of the data. Indeed, outstanding grounded theory grounded theory method, suggested that a grounded theory
work can be done by solo researchers; there is nothing in the needed to be readily understandable, to ‘‘fit’’ the substantive
method that requires collaboration among researchers. area to which it was applied, to be sufficiently general to be
Researchers working alone with their data must be particularly applied to a variety of diverse daily situations, and to provide
reflective about their position and perspective relative to the the user with sufficient control to bring about change in
area of study, recognizing and accounting for how that situations. Grounded theory, to them, needed to be useful and
859
C. J. Watling & L. Lingard

applicable to the area studied (Glaser & Strauss 1967). Notes on contributors
Corbin and Strauss also stressed the importance of ‘‘fit’’,
DR. CHRIS WATLING, MD, MMEd, FRCP(C), is Associate Professor in the
which implies that the findings resonate with both the
Departments of Clinical Neurological Sciences and Oncology and Associate
professionals for whom the research was intended and the Dean for Postgraduate Medical Education at the Schulich School of
participants who took part in the study, as well as applicability Medicine and Dentistry, Western University, in London, Ontario, Canada.
or usefulness. They added a number of other quality criteria, He received his MD from Dalhousie University in Halifax, Nova Scotia,
including the development and contextualization of concepts, Canada, in 1990, and then completed residency training in neurology at
The University of Western Ontario in 1995. He completed a Masters in
logic, depth, variation, creativity, sensitivity, and evidence of
Medical Education at the University of Dundee in 2009, and is presently a
memos (Corbin & Strauss 2008). This last criterion speaks to PhD student in Health Professions Education at Maastricht University. His
the importance of a transparent process, also highlighted by research explores how learners perceive and respond to various learning
Glaser and Strauss. The researcher should be able to demon- influences, with a particular focus on the dimensions of learner receptivity
strate how they derived theory from data; memos elucidate the to feedback.
process of analysis and guard against the sense of ‘‘impres- PROF. LORELEI LINGARD, PhD, is Professor in the Department of Medicine
and Director of the Centre for Education Research & Innovation, in the
sionistic’’ theory development (Glaser & Strauss 1967).
Schulich School of Medicine & Dentistry, Western University, in London,
Charmaz (2006) has suggested her own set of four key Ontario, Canada. She received her PhD in Rhetoric from Simon Fraser
criteria for evaluating grounded theory studies: credibility, University in 1998. Her research program investigates communication,
originality, resonance, and usefulness. Credibility implies that collaboration and socialization on healthcare teams, often using a
the depth and range of data collection is sufficient to support constructivist grounded theory approach. She has conducted studies in a
variety of clinical settings, including the operating room, the intensive care
the analytic claims made. Credibility also depends on a
unit, the internal medicine ward, the adult rehabilitation unit and the
systematic process of comparisons that ensures that the transplantation unit. She is also well-known as a teacher and mentor for
argument that emerges is logical and linked clearly to the emerging qualitative researchers in health professions education.
data. Originality implies that the research offers new insights,
fresh conceptual understandings, and that the analysis is
theoretically or socially significant. Resonance implies that the Note
grounded theory makes sense to the participants and captures
1. Here and elsewhere, we draw on this example from our
the essence and fullness of their experience. Usefulness
own work to illustrate the grounded theory method. We have
implies interpretations that can be used in day-to-day situa-
done so in order to unveil some of the hidden aspects of the
tions by individuals who inhabit the world under study
research process, which, although critical to the final product,
(Charmaz 2005, 2006). One can appreciate considerable
often do not form part of published manuscripts.
overlap in these criteria, even though they were developed
by individuals who approach grounded theory from very
different paradigmatic perspectives. These criteria can arm
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