PostprintThis is an author-produced PDF of an article published in [Qualitative Health Research] AbstractIn this article, the authors clarify a framework for qualitative research, in particular for evaluating its quality, founded on epistemology, methodology, and method. They define these elements and discuss their respective contributions and interrelationships. Epistemology determines and is made visible through method, particularly in the participant-researcher relationship, measures of research quality, and form, voice, and representation in analysis and writing. Epistemology guides methodological choices and is axiological. Methodology shapes and is shaped by research objectives, questions, and study design. Methodologies can prescribe choices of method, resonate with particular academic disciplines, and encourage or discourage the use and/or development of theory. Method is constrained by and makes visible methodological and epistemic choices. If we define good quality qualitative research as research that attends to all three elements and demonstrates internal consistency between them, standardized checklists can be transcended and innovation and diversity in qualitative research practice facilitated.

Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients' independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals' autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients' treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients' autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy.KEY WORDS: personal autonomy; professional-patient relations; clinical ethics; relationship-centred care.

BackgroundQualitative methodologies are increasingly popular in medical research. Grounded theory is the methodology most-often cited by authors of qualitative studies in medicine, but it has been suggested that many 'grounded theory' studies are not concordant with the methodology. In this paper we provide a worked example of a grounded theory project. Our aim is to provide a model for practice, to connect medical researchers with a useful methodology, and to increase the quality of 'grounded theory' research published in the medical literature.MethodsWe documented a worked example of using grounded theory methodology in practice.ResultsWe describe our sampling, data collection, data analysis and interpretation. We explain how these steps were consistent with grounded theory methodology, and show how they related to one another. Grounded theory methodology assisted us to develop a detailed model of the process of adapting preventive protocols into dental practice, and to analyse variation in this process in different dental practices.ConclusionsBy employing grounded theory methodology rigorously, medical researchers can better design and justify their methods, and produce high-quality findings that will be more useful to patients, professionals and the research community.

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Jansen and colleagues explore the role of shared decision making in tackling inappropriate polypharmacy in older adults Too much medicine is an increasingly recognised problem, 1 2 and one manifestation is inappropriate polypharmacy in older people. Polypharmacy is usually defined as taking more than five regular prescribed medicines.3 It can be appropriate (when potential benefits outweigh potential harms) 4 but increases the risk of older people experiencing adverse drug reactions, impaired physical and cognitive function, and hospital admission. [5][6][7] There is limited evidence to inform polypharmacy in older people, especially those with multimorbidity, cognitive impairment, or frailty.8 Systematic reviews of medication withdrawal trials (deprescribing) show that reducing specific classes of medicines may decrease adverse events and improve quality of life. [9][10][11] Two recent reviews of the literature on deprescribing stressed the importance of patient involvement and shared decision making.12 13 Patients and clinicians typically overestimate the benefits of treatments and underestimate their harms.14 When they engage in shared decision making they become better informed about potential outcomes and as a result patients tend to choose more conservative options (eg, fewer medicines), facilitating deprescribing. 15 However, shared decision making in this context is not easy, and there is little guidance on how to do it. 16 We draw together evidence from the psychology, communication, and decision making literature (see appendix on thebmj.com). For each step of the shared decision making process we describe the unique tasks required for deprescribing decisions; identify challenges for older adults, their companions, and clinicians (figure); give practical advice on how challenges may be overcome; highlight where more work is needed; and identify priorities for future research (table). 17 18 Process for deprescribing with older adultsStep 1: creating awareness that options existThe clinician and patient acknowledge that a decision can be made about continuation or discontinuation of medicines, and that this requires input from both clinician and patient. When to initiate discussions about deprescribingPrescribing new medicines is often straightforward, driven by a new diagnosis, symptom, or test result. When to consider ceasing medicines is less clear.12 Possible triggers include the number of medicines taken (perhaps ≥10); a new symptom that may be an adverse effect of a medicine; identifying high risk, ineffective, or unnecessary medicines; apparent non-adherence; or changed treatment priorities. 19 Most of these situations can be identified only by a medicines review. Reviews can be triggered by important life transitions (such as hospital admission, a new diagnosis, or seeing a new doctor) and can be initiated by the clinician or patient, but they are often Older people's attitudes towards medicineClinicians may be reluctant to initiate discussions about deprescribing with older people, believing tha...