Understanding Collaboration Between Social Workers and Physicians

Abstract

This article builds on prior analyses of data collected from a qualitative study of 50 pairs of social worker-physician collaborators in. This article presents the elements of a typology of collaborators from both professions developed from those analyses. The typology was also applied to the entire sample and each respondent characterized according to type (traditional, transitional or transformational). Further analysis was done to evaluate the relationships between type and collaborative perspectives. The sample was primarily transitional (56%-58%) and there were more traditional social workers (22%) and transformational doctors (24%) than anticipated. Social workers, as a group, were much less satisfied with the doctors than the doctors were with them although both groups of traditional respondents were the most dissatisfied. Both groups were least transformational in relation to control over decision making.

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Qualitative Health Research
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DOI: 10.1177/1049732304269676
2004 14: 1387Qual Health Res
Janice M. Morse
Constructing Qualitatively Derived Theory: Concept Construction and Concept Typologies
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10.1177/1049732304269676QUALITATIVE HEALTH RESEARCH / December 2004Morse / QUALITATIVELY DERIVED THEORY
Keynote Address: Fifth International
Advances in Qualitative Methods Conference
Constructing Qualitatively Derived Theory:
Concept Construction and Concept Typologies
Janice M. Morse
Although concepts differ in scope, specificity, and function within qualitatively derived the-
ory (QDT), and the organization and integration of concepts is essential for the attainment
of theoretical integrity, this topic has not been discussed previously in the literature. In this
presentation, the author discusses the derivation and the kinds of concepts that qualitative
inquiry generates. She examines the various positioning of certain types of concepts in
emerging theoretical schemes and how the contribution of those concepts to completed the-
ory varies according to the researchers’ agenda and the various roles assumed by different
types of concepts.
Keywords: qualitatively derived theory; concept development
Although the goal of most qualitative inquiry is the development of theory, the
actual process of theory construction has been overlooked. In research texts, a
great deal of effort is spent explicating processes of coding and developing catego-
ries and themes, but the transformation of these categories into concepts, determin-
ing the position of concepts in the emerging theory, and the actual structure of the
theory have been poorly described.
The major exception is in grounded theory, which has as its goal the develop-
ment of midrange theory. The theory in grounded theory has a particular structure.
As it is used to describe a process, a completed grounded theory is usually concep-
tualized in stages or phases. However, a thematic central process (that is, the core
variable [see, Glaser, 1978], or the Basic Social or Psychological Process [see Strauss,
1987]) remains integral throughout these stages or phases. It is this core variable
that accounts for most of the variance (Glaser, 1978) and is the focus of the theory.
Ethnographic methods, on the other hand, have been concerned with descrip-
tive and explanatory theory but have not developed formal or prescribed processes
that dictate the structure of the theory. With the recent interest in multiple-method
1387
AUTHOR’S NOTE: This article was presented as a keynote address at the Fifth International Interdisci-
plinary Advances in Qualitative Methods Conference, January 2004, in Edmonton, Alberta.
QUALITATIVE HEALTH RESEARCH, Vol. 14 No. 10, December 2004 1387-1395
DOI: 10.1177/1049732304269676
© 2004 Sage Publications
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research and the movement away from the single project toward research programs
that increase the scope, depth, complexity, and significance of qualitatively derived
theory (QDT), the role of concepts in the development of QDT requires serious
reconsideration—perhaps even the development as a research method in its own
right.
Of importance to my approach of exploring concept construction and the posi-
tioning of concepts within QDT are the multiple ways that concepts are used within
a theoretical structure. Note that a concept may be used according to the original
definition of concept, that is, as a label; it may be subsumed as an internal attribute
of a more abstract concept; or it may be exploredfor its role as a concept or as a com-
ponent of theory. To add further confusion, the same concept label can be treated as
a subtheory within a larger theory or as a theory in itself. Thus, the structure of the
concept and its position in a theory vary depending on the context and the purpose
of its use and how the researcher elects to conceptualize and use it.
Let me explain further: Social support may be considered as (a) a concept—in
fact, it was introduced as a scientific concept by Kaplan in 1974 and has since been
defined consistently in the literature. Social support has antecedents and conse-
quences, attributes and boundaries. It can, however, be used in other ways: (b) as an
attribute, or a part of another concept, for instance as an attribute of coping; or (c) as a
concept within a theory, such as a theory of reciprocity. It can be used as (d)a
subtheory, or a theoretical component of larger theory, for instance positioned within
a theory of caregiving; or (e) it can be considered as a theory in itself—as a theory of
social support. In each of these examples, social support changes its scope and its
relationship to other concepts and theories, and its role in the theoretical scheme is
altered.
Nevertheless, it is essential for researchers to be aware of how the concept is being
used and whether it is an isolated entity or linked with other concepts. In each role, the
position of the concept in a theoretical scheme is at some point a deliberate decision
made by the researcher according to certain conditions. Perhaps the scope of the
study was restricted by certain limitations, such as by concerns of feasibility (limita-
tions of cost, time, expertise, and so forth). Its role might have been determined by
the researcher’s scientific agenda and goal (from researcher interest to the type of
knowledge required, outcome/application needed, or purpose, such as the identifi-
cation of an intervention). Or its role and scope may have emanated from the stage
of the research program (in which the knowledge about the concept is necessarily
and logically analyzed prior to theory development).
Thus, again referring to the above example of social support, it is evident that
the concept may be treated with varying degrees of abstraction, from a part of the
whole to the entire theoretical scheme, and it can vary in scope from the
microanalytic to something macro, broad, and comprehensive. It may be analyzed
as a single entity, as a concept, or analyzed within a cluster of allied concepts. It may
be viewed statically in a single point in time or within a dynamic interaction system,
modified over time. The position and use are not fixed by the concept, but the choice
remains with the researcher who determines how it will be used within a particular
theoretical scheme.
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THE DEVELOPMENT OF QUALITATIVE CONCEPTS
Where do qualitative concepts come from? In qualitative inquiry, concepts may be
derived from interview data or imported from the literature. Concepts found in or
derived from interview data might be everyday concepts (i.e., lay terms that are
defined in the dictionary or are newly emerging slang terms) or scientific concepts
(i.e., concepts developed for scientific use as operational definitions) that have been
used extensively in qualitative or quantitative research, and adopted into lay lan-
guage. Everyday concepts may be new slang terms not yet defined in the dictionary,
lay concepts that are defined in the dictionary, lay concepts developed to the point
that they are now used in the scientific literature, or a scientific concept now
adopted into the lay literature. An emerging lay concept may be a slang term. For
instance, in Canada, a “double-double” refers to an order of coffee with two sugars
and two creams, and the term has recently been formalized in the Canadian Oxford
Dictionary (Cotroneo & Hutsul, 2004). Trust is an example of a lay concept that is
now increasingly appearing in the research literature and maturing into a scientific
concept (see Hupcey, Penrod, Morse, & Mitcham, 2001).
Scientific concepts, on the other hand, are developed in quantitative research to
facilitate inquiry by identifying phenomena, labeling, and creating operational def-
initions. Usually, scientific concepts are clearly defined and delineated when intro-
duced in the literature. Alternatively, researchers might find a scientific concept that
has been used to the extent that it becomes an everyday word and has been incorpo-
rated into the dictionary (i.e., an everyday scientific concept). An example of such a
concept is coping. Thus, everyday concepts come from use in language. Although
these concepts are developed linguistically, the process is facilitated by science.
Development of Concepts Using Qualitative Inquiry
Concepts are developed within qualitative inquiry by developing data clusters as
categories or identifying commonalities as themes, labeling or naming the category
or theme, and then developing a definition for each. Next, the characteristics of the
categories and themes are further identified, the conceptual boundaries delineated,
and the attributes identified. This process is identified below.
Step 1: Building Categories and Themes
Principles of induction demand that concepts first be derived by identifying com-
mon segments of data, accruing these data to form a category and applying a label,
or emic tag. An emic tag is a label derived from the category that actually occurs in
the data and that best describes the category as a whole. The next step is to develop a
detailed description of the category. If this description fits the description of a con-
cept in the lay or published scientific literature, then the concept label already in use
replaces the emic tag. This is to prevent the proliferation of the same or similar con-
cepts with different names, basically referring to the same sets of behaviors, from
cluttering the literature. Furthermore, due care must be taken to avoid developing a
single concept with many slightly different meanings applied to the same concept
label.
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Step 2: Naming the Concept
If a description of the concept cannot be located in the literature, then the researcher
has the prerogative of replacing the emic tag with a new name and introducingitas
a new concept. Thus, when gaps are discovered in the literature, new concepts can
be identified, developed, published, and incorporated into education and practice.
Naming a category does not make it a concept, or, at best, without further work,
makes it only an immature concept. It is this next step of further developing the cate-
gories that is often neglected in qualitative inquiry, and some authors even use the
terms category and concept interchangeably, albeit incorrectly.
Step 3: Creating Definitions and
Identifying Boundaries and Attributes
To develop a category into a concept, the category must be saturated, so that the
boundaries are clearly delineated, and the boundaries and concept definition must
be clear enough for others to be able to recognize what is or is not an example of that
particular concept. The characteristics of the category must be identified to the
degree of certainty that the investigator can recognize “noise,” or artifacts—occa-
sional contextual features—from the characteristics or attributes that, by definition,
must always be present for the example to be an instance of the particular concept.
These requirements mean that not all categories are concepts. Although a single
category may be developed into a concept, other outcomes are possible. Two cate-
gories may combine to form a single concept, or, on the other hand, a broad category
might be sorted into two or more concepts. This is important, because concepts do
not occur in the data independently. Their relationships to other concepts, and espe-
cially to lower level concepts, must be demonstrated prior to commencing theory
construction.1
Presently, in qualitative inquiry, there are two further criteria for developing
concepts. First, a concept must be linked to data, or contextualized. Linked to data
means that the derivation of a concept can be traced back to data—and it can be illus-
trated using these data. That is, instances of the concept in use can be provided. Sec-
ond, concepts must be abstract enough to be described and used independently
from the context. This means that the analytic work of identifying attributes, mov-
ing beyond emic tag labels and developing careful definitions, transforms the con-
cept so it is applicable to many similar situations and contexts and the concept can
be recognized in future occurrences.
Although these two criteria initially appear to be contradictory, indeed they are
not. A concept is technically a label, but that label represents or signifies something,
so we must always be able to define it and give examples to illustrate its meaning in
a particular context. The concept also represents many similar instances in other set-
tings—which, incidentally, provides one form of generalizability for qualitative
inquiry. The more abstract, or higher (J. Corbin, personal communication, Decem-
ber 21, 2003), or major (K. Charmaz, personal communication, December 21, 2003)
the concept, the less the concept definition resembles a particular instance, hence
the greater its decontextualization and the greater its usefulness for application to
other contexts.
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Beginning Inquiry From the Conceptual Level
This occurs when the researcher commences inquiry by identifying the concept of
interest rather than waiting for the concepts to emerge. Starting a project using lay
or scientific concepts as the focus of inquiry places the qualitative researcher at risk
of violating validity by working deductively rather than inductively. Suppose, for
example, a researcher was interested in social support as a research topic, and rather
than examining the nature of relationships in the field and waiting for social sup-
port to emerge inductively, he or she began the project using the concept of social sup-
port as it is defined and with all its assumptions.
Qualitative inquiry need not necessarily—or always—start with prior knowl-
edge bracketed. Provided care is taken not to violate principles of inductive validity,
inquiry may begin at an advanced stage, in which the concepts have already been
identified and at least partially explored. In these instances, if the researcher can
identify the boundaries of the concept, these boundaries may be used as a scaffold
with the internal attributes’ being investigated inductively. Alternatively, if partial
information is known about the attributes, the investigator may use this knowledge
as a skeleton, building out from those internal structures (Morse & Mitcham, 2002).
The Importance of Developing Concepts
Why is it important for qualitative researchers to develop concepts? Why not exit
the research process with the analysis at the descriptive stage of categories and
themes?
The refinement of analysis to the level concepts enables . . .
Synthesis. The development of concepts provides a means to identify the attrib-
utes/characteristics needed to synthesize and reduce data, thus moving analysis
beyond the descriptive level to a higher level of abstraction.
Recognition of patterns. The identification of the concept attributes, enables us to
identify similar instances, similar behaviors, and similar occurrences, within data.
These “things” may be not data that are exactly the same—that is, not identical
instances nor replicas—but, rather, things that are have similar characteristics.
Comparison or recognition of variation. Being able to recognize things that are sim-
ilar enables us to see things that are different and to know why they are different or
do not fit within a particular category or concept.
Recognition of new instances. Understanding characteristics or attributes of a con-
cept enables us to recognize or anticipate new occurrences of the same concept in
other contexts, enabling recognition and communication, hence it enables . . .
Expansion of scope. This makes it possible for us to expand beyond the immedi-
ate context.
Generalization. This allows us to apply the concept to similar problems, in differ-
ent contexts.
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The connection to other behavioral sets/concepts. Linking attributes allows us to
connect concepts vertically, horizontally, or progressively in time as concepts paral-
lel, intercept, or merge. This enables . . .
Development of QDT. Other authors have considered that concepts are the
“building blocks” of theory (Chinn & Kramer, 1991). I have problems with this anal-
ogy, for concepts do not stack. They must be theoretically linked, integrated, or con-
nected within the theory, more like fitting a (jigsaw) puzzle together—and one that
is tightly and specifically held in place with Velcro. Such fitting demands that pieces
overlap according to some commonality and dictates that pieces cannot be placed
arbitrarily anywhere in the scheme. Concepts are exceedingly particular about
where and how they fit or are placed within a theory,2so that a molecular structure
would be a more appropriate metaphor than a brick wall.
Types of Concepts
Thus far, we have considered the origins of concepts in qualitative inquiry and their
raison d’être for qualitative inquiry. But before we discuss QDT, we must also con-
sider the forms or types of qualitatively derived concepts.
Concepts account for phenomena, resulting in varying levels of abstraction and
scope, and account for data in different ways. Although I have already also noted
that the researcher’s placement of concepts in theory may account for its level of
abstraction and scope, and this varies with is use, the scope and level of abstraction
also may arise from the very nature of the concept itself and be programmed into its
definition. The scope and level of abstraction are developed primarily from the
nature of the phenomenon it represents and its derivation. Furthermore, the lower
the level of the concept, the closer it is to the data and the more grounded its position
in theory; the more abstract the concept, the higher its position in the theory, the fur-
ther it is from the data, and the greater the number of lower level concepts placed
beneath it. It is these lower level concepts that create the linkages between the con-
text (or data) and the abstract concepts, and it is these linkages that are crucial for
assessing the validity of the theory. Note that the type of concept does not involve
evaluating its maturity (Morse, Mitcham, Hupcey, & Tasón, 1996). Maturity refers to
the concept’s level of development,3not to its level of abstraction.
I have identified the following types of concepts in QDT.
Low-level concepts. The lowest level of concepts are particular concepts. They are
derived directly from data and remain close to the phenomena they represent. As
such, these concepts are local, and narrow in scope, and hence might have restricted
application to other contexts and to new situations, and refer to a particular set of
behaviors. They have limited application and are not widely generalizable. An
example of such a concept may be sorrow. As particular concepts are close to the
data, they may be a part of a more abstract concept—in this instance, sorrow may be
a part of grief, which, in turn, is part of bereavement and a lower level concept than
suffering (see Figure 1).
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Mid-level concepts. Mid-level concepts are generally specialized to a particular
phenomenon. For instance, grief and bereavement are generally applied to the emo-
tional responses to loss associated with death.
High-level concepts. High-level concepts have broad application and often
encompass lower level concepts. For instance, social support may include the con-
cept of reciprocity as an attribute.
Horizontal concepts. These are generally high-level concepts that are extremely
expansive in scope. Various antecedents may give rise to the same pattern of attrib-
utes, and similar outcomes. Suffering, for instance, is a horizontal concept;itisa
broad, highly abstract concept encompassing many specialized, narrower, and
lower level concepts, including grief and bereavement. Linguistic tests may be used
to determine the position, level of abstraction, and logical fit. In the case of suffering,
for instance, you cannot grieve pain or bereave pain, but you can suffer pain, so suffer-
ing is the more dominant, higher level concept. In this instance, the concepts of grief
or bereavement do not compete with suffering, although clearly those at the same
level and applying to similar phenomenon (consider grief and bereavement) may
overlap and compete with each other.
Paradigmatic concepts. Paradigmatic concepts are scientific concepts of a very
high level of abstraction that are applied deductively to a cluster of concepts or a
developing theory. It is important to note that there is no direct link from the catego-
ries or other concepts used in the developing theory; rather, the concept is placed on
to the emerging theoretical scheme.
For instance, an interesting study was recently published that used cultural
safety as a paradigmatic concept (Anderson et al., 2003). The authors write,
In the conceptual phase and planning of the research, we had thought it possible to
identify and name “culturally safe” and “culturally unsafe practices.” In fact, in our
initial attempts to code the data, we developed a category for cultural safety,
Morse / QUALITATIVELY DERIVED THEORY 1393
FIGURE 1: The Horizontal Concept of Suffering
NOTE: The horizontal aspect of suffering encompasses many related concepts, including the mid-level
concepts of bereavement and grief, and the low-level concept of sorrow. Paradigmatic concepts are
applied deductively rather than emerging from the data.
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suggesting an assumed transparency of the concept (p. 204). . . . The quandary for us
was that cultural safety did not announce itself in the transcripts—it was not a
“thing” that could be “found,” but became interpretative work on our part....Aswe
reexamined the data to get a handle on the concept of cultural safety, it became evi-
dent that any code category could illuminate the concept, depending on our interpre-
tation. (p. 206, italics in the original)
Thus, the positioning of the categories in this study under the rubric of cultural
safety was meeting the researcher’s political agenda rather than emerging from the
data. Could another paradigmatic concept be substituted? Yes—within limits. But
we can all think of other concepts that may fit as paradigmatic concepts. Other cul-
tural concepts are obvious, such as cultural competence (Canales & Bowers, 2001),
or even simply safety or feeling safe. But, of greater concern, concepts that are fur-
ther removed from the topic of the study could also be used; for example, caring,
social support, and even trust could slide into the most abstract position on the the-
ory. Note that the higher the level of the concept, the greater the distance between
data and concept, and the easier it is to apply paradigmatic concepts—but also the
greater the risk for “error” or the misattribution of the concept.
TOWARD THEORY DEVELOPMENT
Research—smoothes out contradiction and makes things simple, logical and coher-
ent. (Szent-Györgyi, 1974)
Qualitative researchers must work toward increasingly abstract and powerful theo-
ries. We have matured to the point that our theories can and must be more than nar-
rative descriptions. As we become increasingly sophisticated, so must our theories
become more complex, increasing in scope and maximizing impact. We must start
to develop techniques that will bring together related concepts into a theoretical
whole. The first step in this endeavor is to develop concepts, so their structure (or
anatomy) is clear, and assess the type of concepts to be positioned within the theory.
Because, when constructing QDT, the researcher deliberately determines how
concepts will be used within the emerging theoretical scheme, clarifying the organi-
zation, position, and type of concepts used is essential. Furthermore, understand-
ing the types of concepts in QDT sets the stage for the evaluation of the theory. Stan-
dard criteria for evaluation of QDT consist of six domains: clarity, structure,
coherence, scope, generalizability, and pragmatic utility (Morse, 1997). The task of
evaluating the structure, coherence, and scope is facilitated when the conceptual
structure has been deliberately developed and is clear.
What is next in this process of theory construction? Elsewhere, Morse and
Penrod (1999) recommended “opening” the concepts to find common attributes in
two concepts, and if two similar attributes match, they will then fit to form a com-
mon linkage. As concepts link laterally, horizontally, and vertically in a three-
dimensional scheme, so will theory be formed in a process I call theoretical coales-
cence. In this way, sets of independent and isolated concepts may be brought
together to form a broad and significant theory.
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NOTES
1. Corbin considers categories and concepts to be on a continuum, with the categories closer to the
data than the higher level concepts. Thus, the lower level concepts might provide explanation for the
higher level concepts, and the core category is the concept at the highest level, denoting what the research
is all about (J. Corbin, personal communication, December 21, 2003).
2. Incidentally, this is one reason why concepts or subcomponents of theories cannot be borrowed
casually for use in other theories or moved to create a theory without further inquiry or at least careful
consideration; this is my major criticism of theoretical triangulation.
3. For this reason, evaluating the phenomenological adequacy is not a part of assessing the maturity
of a concept.
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26(3), 196-214.
Canales, K. K., & Bowers, B. J. (2001). Expanding conceptualizations of culturally competent care.Journal
of Advanced Nursing,36(1), 102-111.
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Janice M. Morse, Ph.D. (Nurs.), Ph.D. (Anthro.), D.Nurs. (Honorary), is a professor of nursing and
Scientific Director at the International Institute for Qualitative Methodology, University of Alberta,
Edmonton, Canada.
Morse / QUALITATIVELY DERIVED THEORY 1395
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