This month's interprofessional continuing education (CE) article is a powerful example of medical decision making, using a diversity of cognitive and affective domains to reach consensus; in this particular case, a qualitative research methodology is used-the Delphi methodology. The authors' state, "This article presents the findings of a 3-phase 'Delphi process' involving a group of 'international wound care experts' conducted by the International Skin Tear Advisory Panel to establish a consensus on the product selection guide for the management of skin tears." In their article, the authors describe the Delphi methodology as both a technique and a method. Although the initial use of the Delphi methodology was for consensus building, the model is now increasingly used in participatory action research, along with others, including the nominal group and stakeholder consultation.1 Given the emphasis on authors and editors in biomedical journals to explain and become more transparent about the methodology and reproducibility of a given article,2 I will attempt to illuminate the Delphi research method as a complementary piece to this month's CE.
The name Delphi originates from Greek mythology. The Oracle of Delphi (Greece) was an omnipotent forecaster of the future and was "infallible in authority on all topics, spiritual, moral, ethical, or philosophical in nature."3 Generals sought the oracle's advice on strategy.3 In antiquity, many sites gained a reputation for the dispensing of oracular wisdom. Possibly the best known of these was the sanctuary of Apollo at Delphi, situated on Mount Parnassus in Greece.3 The RAND Corporation developed the Delphi research method in the 1950s.4,5 They wanted to develop a research method using "expert opinion" from many rounds of consensus building, to predict trends and practices in the Cold War.4,5
The method was used initially to forecast the impact of technology on warfare; they used the research method to develop consensus about the threat of nuclear weapons during the Cold War.4 The Delphi method incorporates a group of "experts" who anonymously reply to questionnaires and later receive feedback that is then subsequently reduced to a statistical representation of the aggregate or "group response," after which the process repeats itself winnowing down. The goal is to reduce the range of replies and arrive at something closer to expert consensus. As a qualitative research method, the Delphi Method is a widely used and accepted method for achieving convergence of opinion concerning real-world knowledge solicited from experts5-7 from particular topic areas. The premise of the Delphi model is based on the rationale that "2 heads are better than 1, or [horizontal ellipsis]n heads are better than 1."7
The Delphi methodology was originally a forecasting or decision-making technique using written questionnaires, ostensibly to eliminate the influence of personal relationships and the domination of committees by strong personalities.6,7 In today's world, computer algorithms may remove more personal influence and bias in contributing opinions to a Delphi process. The Delphi consensus building is inductive reasoning or often referred to as "from the bottom up" approach. When an investigator uses inductive reasoning, through observations or measurements, a general pattern often emerges, facilitating the formulation of a tentative hypothesis allowing for further investigation leading to general conclusions. To make a contrast, Delphi is thought to be inductive-reflective and avoids personality conflicts. The Delphi method is related to another technique called "nominal brainstorming and ranking"1 that is also inductive, but requires physical gathering and encourages the contributions of others.1
In reading and interpreting articles, readers have to understand potential bias in participant selection for these types of qualitative studies. For example, in a small field such as wound care, how do we account for biases in participant selection (thought and content leaders, opinion leaders, and "experts"), and what are the methods for participant selection?8 As a qualitative research method, the Delphi methodology is increasingly used to include patients and other stakeholders to understand fully the "patient-centered concerns." The wound care literature is replete with the term patient-centered concern ranging from mere platitudes to trying to measure the patient's perspective in clinical studies. Through the qualitative attributes of the Delphi method, we can capture lived experience and voices of our patients and learn about their concerns through consensus, and we can achieve a better understanding of the effect of our educational interventions and the quality-of-life outcomes of the patients.
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