External validity

So, to what other settings can our emerged theory reasonably be applied? This question relates to the external validity of the research, or what is sometimes referred to as the generalisability of the theory.

5.4.1. Range of cases

There were 17 doctor participants in our first study. Although this would be a small number in a quantitative piece of work, it is within the normal range for qualitative research. This is because the validity of the research relies partly on the depth of the

analysis, and using too many informants could easily lead to a superficial assessment (Malterud, 2001). It is also worth noting that it is not really the number of doctors that is interesting, since they are not the unit of analysis. Instead, in Grounded Theory, each incident is compared with similar incidents and with emerging concepts, meaning that the incident is the unit of analysis. There are several incidents per patient-doctor encounter, and the first study covered over a hundred consultations. In addition, we also conducted interviews and observations when patients were not present, such as during internal meetings and collaborations with colleagues, and these generated even more incidents. The total number of incidents was also considerable in the third study, which consisted of 101 patient encounters, each of which included several analysable incidents. The large number of cases does not, of course, in itself guarantee the external validity of our results, but they do at least indicate the magnitude of the collected material.

5.4.2. Study population

The doctors who were included in the first study came from three different general practitioners’ offices and five different hospital departments in three different hospitals. This was done to ensure the inclusion of a large range of doctors, patients and working environments. All of these settings were situated in Northern Norway, which may have caused a selection bias if these doctors differed from those in the rest of the country, but we have no reason to believe that this is the case. This possible selection issue might also have been mediated by the fact that several of the doctors came from other parts of the country, and had worked and graduated from universities from outside the area. Of course, the patients in Northern Norway may also not be representative of the whole country, because of regional cultural differences. Nevertheless, it is highly unlikely that these differences would affect our theory in any major way, especially since our focus is primarily on doctors’

behaviour. We would, therefore, expect our theory to be valid for how doctors work all over Norway, and possibly also across other Nordic countries because of their similar systems of health care. We cannot, however, transfer our theoretical analysis from the first and second studies directly to medical practice in other countries. This is because the conditions for medical work may differ in places which, for instance, have a more commercially based health care system, and further studies would be necessary to see how the theory fits into other environments and circumstances.

Another exception to our results would be in the realm of psychiatric health care, since we did not include this group in our data. In any event, I believe that the practice of psychiatric health care is sufficiently different from somatic medicine to require studies addressing this particular clinical field in order to assess how the theory applies to these encounters.

The third study only included hospital doctors, and so these results should not be directly transferred to general practice. Many expect general practitioners to be more concerned with providing holistic care for their patients (Alment praktiserende lægers forening, 1978), and so further research would be needed to assess our division between courteousness and existential care in these settings. Nevertheless, our first study, which included general practitioners, did reveal the same process of essentialising for both this group and hospital doctors, indicating that the results of the third study might also be valid in general practice.

5.4.3. Transferability of concepts

What is vital for the external validity of a Grounded Theory is that the end product is not an empirical description, but an empirically based theory which can be transferred to settings other than the one being studied, provided the concepts fit the new environment. Our theory does not concern general practitioners’ consultations or patient communication in hospital departments. The theory of essentialising actually relates to general medical practice, and so is intended to apply to all medical work, in or out of hospitals and with or without patients. The concepts should be transferable to other areas wherein similar medical work is carried out. The theory may also be valid in other settings, for example in psychiatric care, but this must first be tested empirically. What is more, the theory is always open to modification in the light of new data, as previously described. Indeed, including new fields, like psychiatric health care or privatised medical practices, may introduce new and relevant data, which would alter the properties of some of the concepts, or restrict their range, while also widening the scope of the theory.