Showing papers in "Journal of Research in Nursing in 2006"

A critical realist rationale for using a combination of quantitative and qualitative methods

Abstract: Although using a combination of quantitative and qualitative approaches is widely advocated, there is considerable scope for confusion due to the complex ontological and epistemological issues that...

A critical realist rationale for using a combination of quantitative and qualitative methods

Abstract: This paper makes a valuable contribution to the growing debate on method(ology) mixing, and the focus on the epistemology/ontology of critical realism is very welcome and offers a constructive way forward in the ongoing discussion. In this review, however, I wish to focus on two questions the paper leaves largely unanswered. First, there is the question of terminology and, in particular, the use of the terms ‘method’ and ‘methodology’. Despite advocating an anti-conflationist position in which ‘a methodology should not be conflated with the technical aspects of a method’, the authors consistently fail to distinguish between the two. Indeed, in the first paragraph alone they use the term ‘method’ four times and ‘methodological’ twice, apparently interchangeably. The real problem with this mixing of terminology is that it encourages us to regard ‘focus groups, unstructured interviews, textual analysis and ethnographic case studies’ as of the same epistemological order. However, whereas the first two are methods for collecting data, and the third is a method for analysing the data collected by the first two, the final example is a methodology for structuring and rationalising the above methods. Thus, the methodology of the ethnographic case study might employ the data collection method of unstructured interviews and the data analysis method of textual analysis. To confuse the picture further, the authors sometimes use the term methodology to denote a much broader paradigmatic stance, such as in Table 1, where ‘hypothesis testing’ is referred to as a methodology. This rather cavalier approach to terminology makes it difficult at times to understand what the authors are arguing for. Clearly, mixing methods such as qualitative interviews and quantitative questionnaires is not usually considered problematic, and occurs regularly at all epistemological levels. Not only do certain methodologies such as case studies frequently employ a mixture of qualitative and quantitative methods, but even some data collection tools such as questionnaires often include a mixture of closed items which are coded quantitatively alongside free-text items which are coded qualitatively. The question that arises is therefore: at what level or levels is method(ology) mixing problematic? Are we faced with the same issues at the paradigm level of positivism, interpretivism and critical realism as we are at the level of research methodologies such as survey and phenomenology, and at the level of data collection methods such as questionnaires and interviews?

Mixed Methods Research: Positivism Dressed in Drag?

Abstract: The claim that mixed methods is the third methodological movement of the twentieth century could have unexpected consequences for the future of research in the social sciences and health discipline...

Ethnographic evidence: The value of applied ethnography in healthcare

Abstract: The move towards evidence-based healthcare across the industrialised world has raised questions about the nature of evidence, and how good evidence is determined. In response to a hierarchy of evid...

International research collaboration Issues, benefits and challenges of the global network

Abstract: It has been argued that whilst globalisation brings with it significant challenges, it also provides an opportunity for unifying health care activity and that of related research practices across international boundaries. Internationalisation, often confused with globalisation, is a process that can lead to a more extensive pattern of activity and collaboration. International research collaboration in health care has intensified and is frequently regarded as an indicator of quality and a way in which to develop and disseminate scientific knowledge to newly developing countries. There is however little substantive information for researchers new to the global research network on how best to manage the challenges posed by international collaboration, nor ways in which to measure the effectiveness of the same. In this paper we begin by examining the importance of international research collaboration before outlining some of the challenges of global information management. Drawing upon our own experience of j...

Reflexivity: A challenge for the researcher as practitioner?

Abstract: In this article I focus on what it means to have a dual identity as a practitioner and a researcher within an ethnographic research study in the context of a hospice. I discuss moments when I experienced the tension between the roles of researcher and practitioner during fieldwork. I discuss some of the difficulties of managing the boundary between closeness and distance in terms of the observer and participant roles adopted. I explore the challenges for the researcher with a dual identity and how methods of reflexive accounting enhance the credibility of such a study. Thus I document the lived experience of my fieldwork; my thoughts and feelings when the insider and outsider identities collide; and how the identity crisis that resulted was resolved.

‘One expertise among many’— working appreciatively to make miracles instead of finding problems Using appreciative inquiry as a way of reframing research

Abstract: Serendipity plays a role in the articles we read and the ways that we chance upon new ideas, and serendipity brought me to appreciative inquiry (AI). AI, at its heart, is about studying, exploring, actively searching out the best and focusing on what is good, strong, already working and being achieved in organisations. It has been utilised and reported as being effective and transformative in many different aspects of organisational change and change management. AI is based on the 4-D cycle which consists of four phases — discovery (the best of what is or has been), dreaming (what might be), designing (what should be) and destiny (what will be). The cycle starts with the choice of an affirmative topic to study. We used AI successfully within a research study that looked at best practice within multi-agency working with children with complex needs (and their families). Whilst AI is reported, and we experienced it, as an interesting, stimulating and creative way of researching, it is not a panacea and will ...

In command of care: clinical nurse leadership explored:

Abstract: Who are the clinical nurse leaders? What are the qualities and characteristics of clinical nurse leaders? Why are they seen as clinical leaders and what might their experiences of clinical leadersh...

Using grounded theory to research parent participation

Abstract: There are many interpretations and applications of the grounded theory method which have contributed to different understandings of grounded theory and different versions of how the key components (theoretical sampling, constant comparative analysis and theoretical saturation) should be implemented. The esoteric terminology coupled with the matrix style of the analysis process can be challenging for new researchers. This paper uses data from a study on parent participation to illustrate the application of the key components of grounded theory. Grounded theory provides clear guidelines on how to analyse qualitative data and so is a rigorous method that provides structure and direction to the researcher. However, theoretical sampling with vulnerable groups can be problematic and requires further discussion and debate from other users of grounded theory.

Mixed methods and mixed methodologies The practical, the technical and the political

Abstract: This paper presents a discussion of mixed-methods approaches drawing largely on the nursing literature. Taking a supportive but sceptical stance to the mixed-methods approach, the paper considers c...

Exploring the influences and use of the literature during a grounded theory study

Abstract: In a grounded theory study, the literature review is delayed until the theory begins to emerge, it is then used as data. This paper will utilise my own research, a grounded theory study of transition to staff nurse as a process of disrupted continuity, to explore some of the issues stemming from this maxim. It starts by considering the debate around the delayed literature review, before illustrating the use of literature as data. In relation to this process, I have coined the terms deductive and inductive theoretical sensitivity and explain these by example. The ongoing vigilance needed to prevent use of literature becoming a distorting influence will be examined by describing the emergence of my core category. Grounded theory has been criticised for ignoring existing theories and failure to integrate the emergent theory with existing knowledge. This criticism is addressed by use of a priori theory and paradigm cases from my data set. Finally, I reverse the first issue by discussing how knowledge of emerg...

In command of care: Toward the theory of congruent leadership

Abstract: This is the second of two papers that discuss clinical leadership in the light of a research study which explored who the clinical nurse leaders are, what the characteristics and qualities of clini...

Grounded theory sampling: The contribution of reflexivity

Abstract: This paper explores the value of reflexivity for Glaserian grounded theory methodology, using examples drawn from experiences recruiting a sample for a doctoral research project. Reflexivity is highly relevant for grounded theory research due to its foundations in symbolic interactionism. In this study, reflexivity facilitated the identification of factors influencing sample recruitment at a process and a personal level. It provides a vehicle for the identification of the impact of self on the research relationship. Glaser’s (1978, 1992) early works situated personal experience within theoretical sensitivity, and as data to be included within constant comparative analysis method. His later writings (Glaser, 2001) explicitly reject reflexivity as a distraction from the data, seeing constant comparative analysis as having the ability to expose researcher effects on the data. He does not explore researcher influences on study recruitment. The analysis presented here suggests that the impact of the researcher...

Observations of the experiences of people with dementia on general hospital wards

Abstract: This paper is based on research that aimed to explore how people with dementia are cared for in general hospital wards in the United Kingdom (UK). The paper details findings from one phase of data collection, ward based observations. The observations elucidated the ways in which persons with dementia express and portray their ‘selves’, the interpretations made by nurses about the patients with dementia they cared for and the constructions of roles and care environments. The findings demonstrate how a variety of influences affect the way a person with dementia experiences a hospital admission. Nurses' positive or negative interpretations of a person with dementia can lead to the ‘constraint’ or ‘realisation’ of a person's portrayal of self. In an ageing global society, improving the care of older people is a priority. The findings illuminate the central importance of promoting two-way relationships in which the actions of people with dementia are recognised as portraying individuality and identity. The stu...

The politics of the evidencebased practice movements Legacies and current challenges

Abstract: In the United Kingdom the election of the Labour government in 1997 signalled the arrival of evidence-based policy making based on a philosophy of ‘what counts is what works’. Mirroring the emphasis on evidence-based policy-making has been a concern about encouraging the use of evidence in practice. As an ideology it has penetrated the consciousness, discourse and working practices of professionals. However, despite the apparent engagement with evidence-based approaches to care, there remain a number of key areas that stimulate discussion and warrant debate. This discussion paper highlights some of these issues and considers their implications. Specifically, the political context of the evidence-based movements is considered and the resulting consequences outlined. These include issues about how nursing has signed up to evidence-based practice, the way in which evidence is conceptualised and the continuing gap between evidence and practice. Finally, a number of issues are presented that need to be tackled...

Using participant observation to immerse oneself in the field: The relevance and importance of ethnography for illuminating the role of emotions in nursing practice

Abstract: In this paper I draw on the findings of an ethnographic study of fertility nursing in a British fertility unit to explore the relevance and importance of ethnography for illuminating the role of emotions in nursing practice. One of the main findings to emerge from the original study was that infertility was an emotional experience for both staff and patients, and that the organisation of the unit ensured that the potentially disruptive emotions of staff and patients were controlled and remained private. These findings have been reported elsewhere (Allan, 2001, 2002). Drawing on these findings, I discuss the role of ethnography in illuminating the role of emotions in the clinic in two ways. First, I will discuss the nature of the data in ethnography and the relationship between participant observation and interviews. Second, I will discuss the experience of researcher reflexivity and ethnographic authority in ethnography.

Developing a model of participatory research involving researchers, practitioners, older people and their family carers: An international collaboration

Abstract: The care of frail older people and their family carers present significant challenges for welfare systems throughout the world. In order to address their needs, policy initiatives are promoting partnership working between service users, family carers and providers, whereby the former are increasingly involved in the design and evaluation of services. However, participatory models of working raise fundamental issues about power relations and pose important questions about what constitutes ‘evidence’. Several authors identify tensions between movements such as evidence-based practice and initiatives designed to increase the active participation of service users suggesting that there is a need for a new approach to research that reconciles potentially conflicting goals. This paper describes the evolution of a model of participatory research resulting from a collaboration between Sweden and the United Kingdom, which actively involved older people, family carers, service providers and voluntary organisations. The model is underpinned by constructivist principles that have been adapted by the authors so as to be more intellectually accessible to a non-academic audience. The conceptual basis for the model is described and a case study illustrates how it is applied in practice. It is argued that the approach could be adopted widely as a means of more fully engaging older people, their families and a range of service providers in important debates about future health and social care provision.

The policy-practice divide: who has clinical supervision in nursing

Abstract: The role of the NHS in supporting qualified nurses is important for the development and retention of staff. Although there is a general perception that clinical supervision is beneficial and leads to better outcomes of patient care, most literature focuses on the main functions of the supervisory role, the interactions between supervisee and supervisor, or the supervisory process. There is limited large-scale empirical evidence on nurses’ receipt of clinical supervision or their perceived need of its various dimensions. This paper reports findings from a large-scale nationally representative sample of diplomate nurses who qualified between 1997 and 1998. Using Proctor’s model, it discusses the experiences of clinical supervision of 1,918 nurses in early career, 18 months after qualification, from the adult, child, learning disability and mental health branches. The findings show that the receipt of clinical supervision varied among the branches. Just over half of learning disability and mental health dipl...

In command of care: Toward the theory of congruent leadership

Abstract: I concluded my review of the sister-paper to this one (Stanley, 2006) with the observation that it raised more questions than it answered, and left me wanting more. This discussion paper, based on the findings of the empirical study reported previously, goes at least some way towards satisfying this desire. In particular, it challenges the current trend towards the transformational leadership model with a new theory of ‘congruent leadership’. Thus, the unfulfilled promise of the previous grounded theory study to actually deliver a theory is realised in this paper, since the theoretical model of congruent leadership is grounded firmly in data from practitioners themselves. It might be worth briefly reiterating some of the main qualities of the congruent clinical leader, since they challenge some of our basic assumptions about nurse leaders and nursing leadership. Most significantly, congruent leaders are grounded in the present rather than in the future. As the author so memorably puts it, the issue is about where the leader stands, not where they are going, about stance rather than vision. Although congruent leaders might well have a vision, this is not what makes them attractive to others. Rather, it is their ability and desire to stand by their values and beliefs, even when these fly in the face of managerial policy and accepted practice. This moral stance by congruent leaders lies at the heart of many of their other traits, in particular their strong belief in leading by their actions, their ability to empathise both with colleagues and patients, and their willingness to engage in and to promote the ‘dirty work’ of nursing. From my own experience, none of these findings came as a surprise. The only note of discord for me was the finding that creativity was not considered a valued trait in congruent leaders, although the author suggested that this could perhaps be explained as a failure of the research tool to explain fully what was meant by the terms ‘creative’ and ‘artistic’. Inevitably in a paper of this length, some issues could not be fully developed, and I was left feeling curious and a little frustrated by some of the unexplored issues. First, the author’s mention of the ‘dirty work’ of nursing immediately triggered in me thoughts of Schön’s ‘swampy lowlands’ of practice. There are, perhaps, links between congruent leadership and reflection-in-action that could be usefully explored in further studies. Second, the very term ‘congruence’, along with the trait of empathy identified by many respondents, led me to think about Carl Roger’s work on person-centredness. Congruence and empathy, along with non-judgementalism, were the three qualities that Rogers identified as being necessary and sufficient in a

Exploring the influences and use of the literature during a grounded theory study

Abstract: This paper is one of a growing number in nursing research to use experiences from a research study to examine broader methodological issues. In this case, the experiences and insights of a researcher struggling with the problem of when and how to use the literature in grounded theory are used very effectively to illuminate wider issues about theoretical sensitivity. The use of Benner’s work on the development of expertise is very cleverly employed, not only to inform theory-building in the substantive area of the research (the transition from student to staff nurse), but also to illustrate ideas about the expert researcher and the ways that she brings her wider experience to bear on theory development. This leads on to a welcome discussion of ‘diverse reading’ and the ways in which theorists tend to restrict themselves to the ‘relevant’ literature and their own ‘pet theories’. The author makes an appeal for theorists and researchers to read much more widely, and makes the valid point that it is not until we have done so that we are truly in a position to decide what really is relevant. In the case of nurse researchers, I would suggest that this entails reading well outside of our narrow disciplinary boundaries. As the discussion broadens out, it begins to take on a significance beyond grounded theory to encompass all qualitative, and perhaps even quantitative, methodologies. For example, the exploration of inductive and deductive theoretical sensitivity highlights the reflexive nature of all research and the impossibility of coming to a study in a purely objective frame of mind. Not only does our prior reading inevitably influence our approach to the project, but as the author points out, the emerging theory from the project also influences what we subsequently read and what we consider to be significant to our own study. The strength of this paper is the way that the author’s own studies are used both as sources of these emerging ideas and theories, and also as illustrations of how they work in practice. The case of ‘Dick’ works particularly well in describing the way that the author embraced the challenge presented by the existing literature to her emergent theory, and how existing theories might, or might not, shape the theory emerging from the researcher’s own data. Overall, this paper makes some new and significant contributions to our understanding of a very difficult, contested and elusive concept in grounded theory, and does so in a way that is true to the grounded-theory ethos. The focus of the paper

Evidence-based practice and the potential for transformation

Abstract: The political ‘games’ of evidence-based practice (EBP) It is obvious to any informed consumer of healthcare that evidence-based practice (EBP) and politics go hand in hand! Decisions about who has access to what treatment, in what circumstances and to what quality are often and regularly justified by the ‘best available evidence’. For example, in the UK, the debate about access to Herceptin (Trastuzumab) in the treatment of metastatic breast cancer highlights just how political the field is by the resulting government intervention to make the drug available to women – with the Secretary of State for Health intervening in individual cases. The papers in this edition of Journal of Research in Nursing set out the longstanding political quagmire of EBP and they cogently argue for the need for a ‘perspective transformation’ in the field – a transformation that takes us beyond the sterile arguments of hierarchies of evidence, methodological silos and privileging certain forms of knowledge. These papers serve an important purpose of setting out a more unifying voice in the field of EBP that integrates the multiple perspectives of healthcare research, development and delivery. The EBP movement has traditionally focused on particular (and often competing) strands of work about: hierarchies of evidence in decision-making (Canadian Task Force on the Periodic Health Examination, 1979); the privileging of empirico-rational knowledge and the randomised control trial in particular over other forms of knowledge (Sackett et al., 1996); the need to underpin ‘best’ evidence with the ‘generalizability principle’ as opposed to the voices of service-users (Scott-Findlay and Pollock, 2004); and approaches to getting evidence (research) into practice (Kitson et al., 1998). Kemmis (2005) suggests that, in the world of research, ‘games of truth’ take place, and there is little doubt that such games exist in the complex world of EBP. Some of these games are driven by governments under the guise of greater effectiveness, but in reality are more to do with efficiency, risk minimisation, control of the professions and centralisation of policy decision-making. However, despite all of this policy and strategic development,

Using grounded theory to research parent participation

Abstract: While the purpose of most empirical research papers published in academic journals is primarily to present findings, there is a small but growing number that aim to inform us about methodology. This paper falls into the latter category, and while the writers do in fact present some of their data, the aim is to illustrate various points about the process of designing and conducting a grounded theory study rather than to tell us about parent participation in their children’s healthcare. The writers are quite explicit about their aim, pointing out that they are not offering a blueprint, that is, a plan to be followed by other prospective grounded theorists, but rather ‘just one example of how grounded theory may be used’. In my opinion, they are perhaps being over-modest in this claim: their paper provides us not merely with an example but an exemplar, a model of good practice for conducting Glaserian grounded theory. Nevertheless, their point about blueprints is well made, since any writer who uses their own work to illustrate a particular research methodology inevitably treads a thin line between (to shift metaphors) providing directions to a particular destination and describing the view once the destination is reached. What is required of a useful exemplar of good practice is neither of these. On the one hand, a set of directions provides a step-by-step list of instructions which seemingly guarantees a successful outcome if followed correctly. In many ways, this is exactly what Glaser was accusing Strauss and Corbin of doing in setting out a procedural approach to grounded theory that forces the data in a certain direction rather than letting it find its own way. On the other hand, a description of the view focuses too much on the final destination without providing any instructions as to how it was reached. Between these extremes lies the difficult path trodden in this paper of providing a clear, detailed and (most importantly) singular account of many of the key issues involved in conducting a grounded theory study. In particular, it offers exemplars of the complex and often misunderstood processes of theoretical sampling and constant comparative analysis, as well as practical tips on memo writing and the use of diagrams. Furthermore, it never extends its reach by claiming that this is the only (or even the best) way to do Glaserian grounded theory. The reason why this paper works so well where others have failed is that the authors never lose sight of the fact that research, like nursing, is a practice in Schön’s meaning of the term. Doing research is a messy business; there are no inviolable rules or guidelines, no directions which guarantee success and no real alternatives to getting your feet muddy in the swampy lowlands of real-life, everyday practice. To

Never say die A study of cardiopulmonary resuscitation and the National Health Service — comments from an ethnographic enquiry

Abstract: The aim of this paper is to convey the usefulness of an ethnographic approach in understanding the clinical practice of Cardiopulmonary resuscitation (CPR). One of the study findings, concerning the interplay of politics, power relationships and commerce around CPR practice, is used to demonstrate, albeit briefly, how current CPR policy has been driven by perceptions of risk.

Integrating mixed-methods research into healthcare

Abstract: As Bryman (2006: 5) notes in his recent editorial: ‘These are exciting times for writers and researchers concerned with the process of mixing different research methods and approaches to research generally.’ Mixed-methods research has indeed generated a great deal of interest amongst researchers of late; although I am not sure that I would use the term ‘excitement’ to describe this interest. Additionally, it should be observed that social scientists have been mixing methods and data sources for decades. Thus, mixed-methods research is not a new phenomenon, despite its growing popularity. Certainly, the discourse of mixed-methods research has become more visible in recent years, as evidenced in the proliferation of research texts, papers, dedicated conferences and special editions of journals (including this one!). And of course ultimately the launch of the new Journal of Mixed Methods Research (due out in 2007). It is easy to agree with Bryman (2006) when he suggests that there is a need to evaluate the current state of play with regard to mixed-methods research, to take stock as it were, both across and within disciplines. What indeed is the added value that mixed methods approaches to research brings to health care and specifically to nursing practice? Importantly, what do health scientists and nurse researchers have to contribute to the ensuing debate around methodological pluralism? The focus of this edition of Journal of Research in Nursing does not attempt to evaluate the state of the art in mixed-methods research across healthcare; this is a research endeavour all of its own. However, I am optimistic that it has the potential to stimulate the reader’s appetite with regard to the philosophical, ontological, epistemological and pragmatic concerns that require further investigation, particularly in relation to the application and understanding of multimodal research for practice improvement. In the main, debates surrounding the relative benefits and shortcomings of research methods tend to focus on the superiority of one method over another, focusing on the issue of method, sometimes to the exclusion of other important concepts such as paradigms. The literature around mixed-methods research does, to a limited extent, challenge this tradition. However, in my critical view, it is missing a significant and powerful ingredient, that of reflecting back on its own use of language and form of representation (see, for example, Freshwater, 2005). Turning to the literary representations of mixed methods, numerous references can be found to unity and unification, this apparently being achieved through integration. Nursing researchers are particularly fond of using such terminology. DeMarco (2002: 553), for example, argues for the benefit of using two theories to understand the voices of staff nurses. She goes on to say that theory synthesis is

Developing nurse education and practice across the European Union

Abstract: Background This editorial is based on my reflections on the work of the Thematic European Nursing Network (TENN). These thoughts appear to be timely because of the current expansion of the European Union (EU) and the work of the European Commission (EC). In April 2005 the EU membership increased to 25 countries with many individuals becoming more geographically mobile — much of the work of the EC has been to help improve the mobility of the workforce across the EU. Within higher education and, of course, the training of professionals, the EC are progressing with the establishment of a European Higher Education Arena by 2010. Education ministers began the Bologna Process, which fits into the broader framework of the Lisbon objectives. The key aim being for Europe to be a competitive and dynamic knowledge-based economy to enable better jobs and improved social cohesion. The EC is thus supporting projects such as TENN to help to deliver the aims of the Bologna Process (www.dfes.gov.uk/bologna/). The key aims of the Process include the improvement of mobility of students and academics across Europe; the development of three cycles of degrees; a European Credit and transfer system; and diploma supplement and lifelong learning strategies. Thematic Network projects are therefore an initiative within the European Union’s Socrates–Erasmus education and training section. They aim to define and develop a European dimension within a specific academic discipline, or other issues of common interest, through cooperation between university facilities and departments, academic and professional associations, and other partners.

International collaborations in nursing research Priorities, challenges and rewards

Abstract: The purpose of this paper is to present a framework for dialogue for university-based nursing programmes that are planning and developing international research programmes. Future trends will continue to drive the need for international research due to the globalisation of healthcare issues. Nursing, as one of the main providers of healthcare services, can play a larger role in improving healthcare globally, by leading the way in international collaborative research. A definition of international nursing research is offered, as well as a framework consisting of three broad issues for discussing international work. The three foci of the framework are (a) international nursing research priorities, (b) rewards of international nursing collaborations and (c) challenges of these collaborations. Examples of international collaborative nursing research experiences with nurses in Haiti, Taiwan, Thailand and the United Kingdom are examined, along with lessons learned

Qualitative theory testing as mixed-method research

Abstract: While the concept of mixed-methods research is more usually associated with combining quantitative and qualitative approaches, this paper outlines a study that mixed methods by undertaking qualitat...

Mixing art and science A bridge over troubled waters or a bridge too far

Abstract: Nursing commentators exhort that nursing practice is both an art and a science, without really considering the differing philosophical assumptions implicit in the divide. This mixture of competing ideals and philosophies is set within a rigid, fundamentalist medical model of healthcare that compels empirical evidence to be the foundation of decision-making. Some of this evidence is derived from within the emergent methodologies of the social sciences, but there is little credence given to the vast resource of the humanities. The resulting plethora of methodologies has created warring factions between the extremes of the quantitative and qualitative researcher. Beyond this argument is the certainty that the uniting feature of all research is language and, as Bakhtin suggests, ‘language is only in the dialogic interaction of those who make use of it’. To understand how art and science can intertwine to create a human science, an exploration of how nursing is embedded in the heteroglossia of a diverse societ...