Background
Methods
Step 1: Identify the research question
Step 2: Identify relevant studies
Step 3: Study selection
Step 4: Charting the data
Step 5: Collating, summarising, and reporting the results
1. | When is this approach appropriate? |
2. | How to use this approach |
3. | What type of findings to expect |
4. | Potential pitfalls and how to avoid them |
Results
First author | Country and Year of Publication | Aims of study | Participants and setting |
---|---|---|---|
Ab [25] | Netherlands, 2009 | To explore why general practitioners do not follow guidelines on lipid-lowering treatment in patients with type 2 diabetes mellitus, to gain insight into the factors that represent appropriate vs. inappropriate care and tailor interventions to reduce inappropriate care. | 7 purposively sampled general practitioners who had indicated that they were familiar with recently distributed guidelines on statin use in diabetic patients. |
Dee [27] | USA, 1993 | To describe the information needs and information-seeking behaviour of rural physicians with or without hospital library access | 12 rural physicians (9 family physicians and 3 specialists) in Central Florida who agreed to participate after an extensive recruitment drive |
Guerra [24] | USA, 2007 | To assess whether primary care physicians routinely discuss prostate cancer screening and explore the barriers to and facilitators of these discussions | 18 purposively sampled, community- and academic-based primary care physicians |
Guerra [23] | USA, 2007 | To explore the barriers of and facilitators to physician recommendation of colorectal cancer screening | 29 purposively sampled, community- and academic-based primary care physicians |
Jennett [29] | Canada, 1995 | To demonstrate how patients’ charts can be used to provide insights into diagnostic, investigative, and treatment decisions in NSAID gastropathy, to assist in understanding the complexity behind clinical choices | 20 family physicians in active, full-time practice in the Calgary city area |
Lockyer [28] | Canada, 1991 | To obtain information about physician awareness and acceptance of guidelines, determine what influences physicians’ decisions to investigate and treat neonatal hyperbilirubinemia, and identify how physicians preferred to learn about guidelines | 25 physicians (5 paediatricians and 20 family physicians) who prescribed phototherapy for jaundiced neonates in the Foothills Provincial Hospital, Calgary. |
Rochefort [26] | Canada, 2012 | To describe physicians’ decision-making processes, and factors influencing their decisions, regarding treatment choices for hypertension, in order to improve the cost-effectiveness of hypertension management. | 29 primary care physicians in Quebec who used a specific clinical information system |
Sinnott [13] | Ireland, 2015 | To explore how general practitioners make decisions when prescribing for multimorbid patients, with a view to informing intervention design | 20 purposively sampled general practitioners in full-time practice in Ireland. |
First author | How charts were chosen | Topic guide | Average no. of charts per interview | Interview duration | Data analysis | Interviewer (s) background |
---|---|---|---|---|---|---|
Ab [25] | Prior to each interview, a list of patients with type 2 diabetes not being prescribed lipid-lowering medication was extracted from the GP’s electronic medical records by the research team. | Open questions on patient, physicians and organisational barriers | 10-27 charts: as many as possible were discussed in an hour | 60mins | Qualitative: Content analysis | Researcher with unspecified background |
Dee [27] | The charts of all patients seen by the physician during half a day of office practice. | Not provided | 12 charts | Not provided | Descriptive (mostly quantitative) | Doctoral researcher in librarian studies |
Guerra [24] | Interviewee asked to pull 10 charts on men >45 yrs. seen in last 2 weeks, without knowing focus of the study | Unstructured probes informed by the Walsh and McPhee Systems Model of Clinical Preventative Care | 2.3 charts | 30–45 min | Qualitative: Grounded theory techniques | Medical student |
Guerra [23] | Interviewee asked to pull 10 charts on patients >51 years seen in last week, without knowing focus of the study | 4.3 charts | 30–45 min | Qualitative: Grounded theory techniques | Medical student and physician | |
Jennett [29] | Standardised patient visit, with chart then used to stimulate recall | Standardised protocol on the rationale for clinical choices, conditions ruled out. | 1 chart | 20 min | Qualitative: Content analysis | Nurse |
Lockyer [28] | The first neonatal case that participating physicians prescribed phototherapy for during the study period. | Closed and open questions on awareness and acceptance of guidelines, and preferred information sources | 1 chart | 10–15 min | Descriptive (mostly quantitative) | Neonatal nurse |
Rochefort [26] | 2 cases of hypertension newly started on antihypertensive therapy (one in accordance with guidelines and one not) were purposely selected from the interviewee’s electronic health record database by research team | Literature informed questions on the general approach to hypertension and rationale in chosen cases | 2 charts | Not provided | Qualitative: Content analysis | “Trained interviewer” |
Sinnott [13] | Interviewee asked to pull 3-5 charts on patients with multiple long-term conditions and 5 + medications, seen the day of or day preceding the interview | Literature informed prompts on management of multimorbidity in primary care | 2.5 charts | 40–50 min | Grounded theory with constant comparison | General practitioner |
Quality appraisal
When is CSR appropriate?
How to conduct CSR
Recruitment
Choosing the charts
Topic guide
Analysis
Triangulation
The role of the researcher: Training and reflexivity
Ethical concerns
What type of findings might you expect?
Potential pitfalls and how to avoid them
Recall bias
Selection bias
Observation bias
Discussion
Strengths and limitations
Unanswered questions and areas of future research to advance this method
Reflexivity and researcher training
Ethics
Other potential applications of CSR
Alternative approaches to CSR
Description | Advantages | Limitations | |
---|---|---|---|
Think-aloud technique [36] | Participants speak aloud any words in their mind as they complete a task or solving a problem. Can incorporate direct observation, audio or video recording. | As a real-time approach, may give more valid information than retrospective CSR. Links the thinking processes of the participant with concurrent perceptions, thus revealing information in working memory. May be combined with vignettes or simulations. May be used to study individual differences in performing the same task. | In clinical settings, is time-consuming and intrusive for participants. Given the limited capacity of memory, can hinder the participant’s cognitive processes, thus altering performance if tasks involve a high-cognitive load. Needs sufficient instructions and prompts from researcher to ensure sufficient verbalisation takes place, but prompts may then change how people think. |
Case vignettes [38] | A brief carefully written description (or video/audio/photograph etc.) of a person or situation, designed to simulate key features of a real world scenario, is used to pose questions to a research participant. | Inexpensive, practical and safe approach to explore decision-making. Allows standardisation of cases across participants. The context or variables in the vignette can be varied across or within participants to address questions of interest. | Concerns that the artificiality of vignettes threatens external validity. Cannot test the relationship between beliefs in a hypothetical situation and actions in real practice. Risk of observer biases. |
The critical incident technique [39] | Focuses on respondents’ accounts of events that have actually happened (incidents). Incidents are deemed to be critical when the purpose of the action and the outcome of the incident are reasonably clear and relevant to the phenomenon under study. | Systematic five-step process suited to the exploration of dilemmas. Encourages the natural tendency of people to tell anecdotes, but increases their value as data by focusing them onto a limited area of interest. Facilitates exploration of two sides of behaviour: good and bad; effective and ineffective; avoidable and unavoidable etc. Interview focuses on the specific reasons for actions and behaviours. | Focuses on skewed examples of care rather than routine cases. Operators may be reluctant to participate if they feel their performance is being scrutinized. Reliance on memory alone can result in data degradation and other data collection problems. |
Video-stimulated recall [40] | A method of enhancing participants’ accounts of a consultation using a video-recording of the event to encourage and prompt recall in a post-consultation interview | A useful method to explore specific events within the consultation; mundane or routine occurrences; non-spoken events; and “taken for granted practice”. Visual stimuli may be a stronger stimulus for recall and allows participants to comment on non-verbal behaviours. Can be used to explore clinician and patient views. | Complex, costly and time-consuming. May generate a lot of data. Ethical hurdles of recording patient-encounters. Inappropriate probing during the interview may lead to reflection and analysis rather than recall of events as they happened. |
Audio-stimulated recall [41] | A method of enhancing participants’ accounts of the consultation using an audio-recording of the event to encourage and prompt recall in a post-consultation interview | Facilitates analysis of conversation and verbal communication techniques. Less intrusive than video-recordings. Can be used to explore clinician and patient views. | Audios reproduce only a portion of the original experience. Inappropriate probing during the interview may lead to reflection and analysis of actions rather than recall of un-consciously produced patterns of action. Time consuming. |
Chart- stimulated recall | During the interview, a patient’s chart is used as an aide-memoire to the physician’s recall of a case while the interviewer probes the reasons why certain decisions were made | Can add to the specificity of interview data, bridge the gap between real and perceived practice, and facilitate a deeper exploration of cognitive reasoning | Lack of information on use of chart-stimulated recall by non-clinical researchers, specific ethical issues and the number of charts required to give adequate representation of practice. |
Protocol analysis [36] | A verbal process which reveals the “step-by-step” progression of a person’s problem-solving ability | Can reveal in detail the information that participants are concentrating on while performing their tasks. Can be combined with think-aloud technique. | Can be problematic in ill-structured tasks in complex environments. Has been criticized for being too reductive. |
Material probes [42] | Objects (e.g. keepsakes, awards, trophies, and collectibles) or places (buildings, wards, open spaces) are used to prompt participants and elicit responses or memories during interviews. | Can help to keep the participant focused on a topic and provide a trigger for memories that might otherwise remain buried or actively excluded. Researcher can suggest materials or let participant choose them; participants can choose items they see as important to the topic, thereby adding to the depth of the discussion. | Allowing participants to choose objects can lead to the researcher losing some control over the interview and what is discussed. Choice of materials should be aligned with the research aim to ensure coherence across interviews. |
Photo elicitation [43] | Inserting a photograph into a research interview to expand sensory awareness, increase the reflexive process and allow researchers to glean insights that might not be accessible via verbal-only methods. | Photos can be provided by the researcher, the respondent, or both. Elicit longer and more comprehensive interviews by overcoming the fatigue and repetition of conventional interviews. | Ethical issues regarding consent of photographed individuals. Participant chosen photos may veer towards the positive rather than negative end of their experiences. May not lead to a deep commentary if photos do not pose anything extra-ordinary or represent only taken-for-granted aspects work or activities. |