Marrow C (1996) Using qualititative research methods in ...



|Marrow C (1996) Using qualititative research methods in nursing. Nursing Standard. 11, 7, 43-45. |

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|Using qualitative research methods in nursing |

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|This paper explores the problems and dilemmas encountered while conducting a longitudinal qualitative research study in the clinical nursing |

|environment and highlights strategies that helped to overcome the difficulties of using observations and interview techniques. The author |

|concludes that research within practice is essential to ensure successful implementation. |

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|Date of acceptance: May 17 1996. |

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|Carol Marrow BA(Hons), MPhil, Cert Ed, RGN, RMN, is Senior Lecturer, University College of St Martins Education Centre, Furness |

|General Hospital, Barrow-in-Furness.   |

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|KEY WORDS: |

|NURSING RESEARCH |

|QUALITATIVE RESEARCH METHODS |

|NURSING PRACTICE |

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|Novice researchers are often unsure of the most appropriate methods to use in their research. However, critical evaluation of data collection |

|methods used in other studies can help to develop some understanding of the methodological issues. |

|It is important not to diminish the problems encountered when conducting a study. However, the benefits of qualitative methods in the clinical |

|field should not be ignored as it is valuable to develop theories that recognise clinical constraints. This is essential to the profession of |

|nursing with its emphasis on humanism and caring for the whole person. Indeed, Duffy (1985) suggested: 'Researchers of the phenomenological |

|schools, for example grounded theorists, reject the assumptions of positivism, and attempt to humanise the research process.' Research |

|methodologies which enable the participants to interpret their behaviour in a meaningful way are essential to the qualitative approach. |

|This study explored supervision issues and involved observing and interviewing a cohort of Project 2000 students and their clinical supervisors |

|(n=30). Data was collected using direct observations and |

|semi-structured interviews and analysed by the use of a continuous, comparative method (Glaser and Strauss 1967).[pic]OBSERVATION |

|One of the main reasons for choosing observation as a method of data collection in this study was to allow what actually occurred to be seen and|

|recorded, rather than solely relying on the participants' perceptions of what had taken place. Observation techniques as a method of choice, |

|however, are not without their problems and researchers should be aware of the issues to try to avoid any complications. |

|In the clinical field, the best positions for observation should be identified as well as a suitable area for writing field notes, otherwise |

|valuable time can be wasted when the investigation commences. In this study, it proved difficult to find a suitable place to write the field |

|notes as many of the wards where observation took place did not have a quiet room, apart from in the mental health settings. The staff canteen |

|had to be used on occasion, which was not ideal as it was usually noisy. |

|Leininger (1985) highlighted other potential difficulties and stated that the observer must overcome at least two major hurdles concerning his |

|or her relationship with the participants studied. The first of these is to gain entry. |

|In this study, the students had been approached and the research explained before entering the ward. However, it was also important to make |

|myself known immediately on entering the ward and to explain again to both the students and qualified staff (supervisors) why I was there. I was|

|never once refused entry and was always made welcome, therefore it seemed the participants did not feel threatened by my presence. This was not |

|always apparent in practice as some of the supervisors repeatedly asked: 'What are you looking for?' |

|The second hurdle Leininger (1985) postulated was to establish rapport and develop trust within the social group. The wards were generally very |

|busy on the occasions when the observations took place and it was clear that the participants often became so immersed in their work that they |

|forgot my presence. This was supported by evidence from the subsequent interviews. When asked how it felt being observed practising, one student|

|stated: 'It felt very uncomfortable at first; I felt I was being scrutinised but I was surprised how soon I forgot you were there and when you |

|later came to seek me out for interview, I thought you had already gone...knowing you were a nurse helped, it made me think that you would |

|understand.' |

|Even when I tried to keep the participants informed, there were occasions, particularly in the early stages of the study, when I felt that they |

|(mainly the qualified nurses) appeared suspicious of my real motives. This warranted careful handling of the staff through active communication |

|on all aspects of the research. This continuous form of interaction, although important for information giving, might have caused many problems,|

|not least developing too deep an involvement in the ward culture on my part. This was one of the reasons for being a non-participant observer. |

|[pic]NON-PARTICIPANT OBSERVATION |

|Participant observation was rejected in this study principally because the researcher often does not reveal his or her identity to the group |

|being studied. This may place conflicting demands on the part of the researcher. Gold (1958) saw these conflicts as feelings of guilt concerning|

|the way information has been obtained and the consequent need to reveal one's true identity. This in turn may prevent the researcher from |

|performing convincingly in the role. |

|Another difficulty is the ability to observe objectively, as the researcher may become so immersed in the participants' world that there is the |

|danger of 'going native'. In this particular study, it may also have been difficult to obtain permission from hospital managers if my identity |

|had had to be concealed. |

|Non-participant observation also allows the researcher to take time out to write field notes and reflect on what has been observed and the |

|issues raised. These included the actual behaviour of the participants, the theoretical application and the methodological problems. |

|Bannister (1981) suggested that thinking time within a research project is vitally important; for example, problems with the observation |

|framework can be addressed by acknowledging apparent weaknesses and, furthermore, theories can be thought through and applied to the |

|observational notes. It is also important to take regular time out to combat lapses in concentration caused by fatigue or boredom; occasionally |

|I considered leaving the research area earlier than scheduled and had to remind myself that this might mean missing relevant data. |

|It proved difficult not to become involved with nursing care interventions; doing so may have interrupted the flow or the focus of thinking with|

|respect to the research issues. Moreover, observing practice that appeared questionable by my own personal standards caused significant role |

|conflict; I was forced at times to consider which role was more important, nurse or researcher? Many researchers believe that remaining outside |

|the research scene is essential, so that the natural situation will not be changed by the researcher's presence. The researcher must analyse the|

|complete situation objectively otherwise there is a danger of credibility being lost and further access being refused (Sapsford and Abbott |

|1992). Bogdan and Taylor (1975), however, suggested that some researchers believe that passive observation condones such behaviour. |

|One helpful way of overcoming the problem of not participating was to interview the participants immediately after observations had occurred. |

|After observing on the wards the field notes were carefully evaluated and, as stated earlier, issues that needed clarification were identified |

|and noted. Sometimes these issues did have ethical implications and it was useful to be able to explore them further in a safe and trusting |

|environment. Becker and Geer (1970) suggested that observers can interview their subjects at the end of the field work. They should then have |

|the trust of the study participants and sufficient relevant information to make their questions 'poignant and relevant to the interests of |

|subjects' (Bogdan and Taylor 1975). [pic]SEMI-STRUCTURED INTERVIEWS |

|As suggested, another data collection method used in this study was semi-structured interviews based on an open questioning technique called |

|'the funnel' (Cohen and Manion 1989). This technique generally commences with a broad statement or question after which the focus progresses to |

|more specific issues. |

|The interviews, comprising five open-ended questions, were audio-taped to allow the feelings of the participants (students and supervisors) to |

|come across and to ensure that no important issues were omitted. The interviews were taped with the participants' consent. |

|Tape recordings are felt to be useful for capturing each participant's mood or strength of feeling on issues raised. However, when relying |

|completely on tape recordings, non-verbal behaviour is often ignored. Breakwell (1990) maintained that it is useful to note points where |

|non-verbal communication was strong; this can help to clarify whether what respondents are saying actually correlates with what they are |

|feeling. For example, breaking eye contact when discussing an issue may indicate that the individual feels uncomfortable with that particular |

|issue and does not wish to discuss it further. |

|In this study, the interviews were taped with one exception (a student who was uncomfortable with the tape recorder) and key issues were noted. |

|As already stressed, this was to prove useful when it came to transcribing the data, as the notes emphasised the substantial points and |

|reinforced the feelings of the participants. Each tape recording was transcribed in full. |

|The supervisors were also interviewed in the same conversational style. I had thought that the interviews with the qualified nurses would be |

|easier and in greater depth because I presumed they would be more comfortable and knowledgeable when discussing their supervisory role and the |

|students' learning. It was, therefore, surprising when the students proved generally more vocal than the qualified staff. It could be that the |

|students welcomed the opportunity to vent their feelings on their clinical learning experience, whereas the pressure of work could have induced |

|guilt feelings in the qualified staff for leaving the patients. However, to have interviewed them at a separate time and location would have |

|been difficult organisationally, and the issues that arose from the observations would not have been as compelling if referred to out of |

|context. |

|Many issues observed were clarified at interview. This was crucial as many constraints on practice were identified; for example, lack of time, |

|poor staffing levels and inadequate skill-mix resulting in poor student supervision. In addition, on many occasions a task-centred approach to |

|care interventions was used. |

|The interviews were conducted in a relaxed conversational style. The rapport that developed was important in helping to elicit more in-depth |

|information by encouraging the students to feel both safe and confident. Massarik (1981) suggested various types of interview; these ranged from|

|the hostile interview to the humanist phenomenal interview where there is mutual respect and sharing. The latter is characteristic of the |

|interviews used in this study. |

|The students were encouraged to feel relaxed and this was enhanced by asking them to discuss their clinical learning experiences generally |

|before focusing on specific areas. A technique devised by Leininger (1985) was used. She described how the statements 'tell me' and 'I would |

|like to hear about' tend to open the 'idea gate', and further explained that: 'These stems permit the informant to tell the story in his or her |

|own way and style...the informant supplies the information more easily and makes it unnecessary for the researcher to ask literally hundreds of |

|questions and often get less information.' In this relaxed style topics that arise can be explored, provided that the interview focus is adhered|

|to and that any misunderstandings are resolved to avoid pursuing irrelevant information. |

|The skills of the interviewer are also important in encouraging the participants to talk freely and comfortably. Although relatively |

|inexperienced at research interviewing, some experience in mental health nursing and counselling helped me to adopt a facilitative rather than a|

|controlling stance. |

|This counselling approach can also be problematic, however, as the students often saw this as a chance to complain about the Project 2000 |

|course. This was difficult to handle at first as I felt that these issues needed to be discussed otherwise the interview would not progress. The|

|problem was eventually resolved by suggesting that the issues be discussed at the end of the interview if time was available or, alternatively, |

|I could see the students again. This latter offer was never taken up and I feel that the students raised many grievances which remained |

|unresolved. |

|Interruptions were also a problem. Many of the interviews were conducted in the ward clinic as there was no other private area available. This |

|sometimes interrupted the conversational flow and it often took some time to re-establish the discussion focus. Many of the interruptions were |

|made by busy nursing staff requiring equipment. It seemed that the research participants had difficulty returning to the interview and one of |

|the interviewees suggested one reason for this: 'It is sometimes difficult to concentrate when you know the ward is busy.' |

|The interviews could have been more successful if a specific time had been identified for them and adhered to, as well as conducting them in a |

|room where disturbances were kept to a minimum. [pic]COMBINING METHODS |

|As previously asserted, one of the benefits of using interviews as well as observations was that they allowed the issues to be explored further.|

|This also helped in coming to terms with the researcher's lack of participation during the observations. A combination of different research |

|methods can also increase the validity of the findings. Becker and Geer (1970) stated that: 'An observation of some social event, the events |

|which precede and follow it, and explanations of its meanings by participants and spectators, before, during and after its occurrence. Such a |

|datum gives us more information about the event under study than data gathered by any other sociological method.' Utilizing a combination of |

|data collection methods in this study overcame two potential problems: |

|To have used interviews alone would only have represented the participants' viewpoint |

|To have used observations exclusively would not have allowed the participants to present their own perspective on what had occurred. |

|[pic]CONCLUSION |

|The utilization of direct observations and semi-structured interviews in this study was beneficial to data collection. On occasions, problems |

|were experienced and many of the problems encountered had not been anticipated initially. |

|It is clear that the process can be enhanced by careful preparation. The environment should be vetted thoroughly before starting the study and |

|the role of the researcher should also be clarified at an early stage. The aims of both the observations and interviews should be clear and |

|opportunities to discuss sensitive issues should be offered. The participants should be fully informed about the research aims and time for |

|reflection and note taking should be a priority. |

|The opportunity to explore issues in the 'real nursing world' where the context is part of the research itself is a significant advantage of |

|this type of research. The many variables within nursing practice, although problematic, can be taken into consideration to produce a richer |

|picture. |

|When empirical research is conducted away from the clinical setting, the findings can be idealistic and estranged from the reality of clinical |

|constraints. This highlights the importance of conducting research in the subjects' natural environment where the researcher becomes aware of |

|the problems surrounding practice, and the risk of implementing research that is far removed from that reality is reduced. |

|[pic]REFERENCES |

|Bannister D (1981) Personal construct theory and research method. In Reason P, Rowan J (Eds) Human Inquiry: A Sourcebook of New Paradigm |

|Research. Chichester, John Wiley & Sons. |

|Becker HS, Geer B (1970) Participant observation and interviewing: a comparison. In Filstead WJ (Ed) Qualitative Methodology: Firsthand |

|Involvement with the Social World. Chicago IL, Markham. |

|Bogdan R, Taylor SJ (1975) Introduction to Qualitative Research Methods: A Phenomenological Approach to the Social Sciences. New York NY, John |

|Wiley. |

|Breakwell GM (1990) Interviewing, Problems in Practice. London, British Psychological Society, Routledge. |

|Cohen L, Manion L (1989) Research Methods in Education. Third edition. London, Routledge. |

|Duffy ME (1985) Designing nursing research: the qualitative- |

|quantitative debate. Journal of Advanced Nursing. 10, |

|225-232. |

|Glaser BG, Strauss AL (1967) The Discovery of Grounded Theory. New York NY, Aldine De Gruyter. |

|Gold RL (1958) Roles in sociological field observation. Social Forces. 36, 217-223. |

|Leininger M (1985) Qualitative Research Methods in Nursing. New York NY, Grune & Stratton. |

|Massarik F (1981) The interviewing process re-examined. In Reason P, Rowan J (Eds) Human Inquiry: A Source book of New Paradigm Research. |

|Chichester, John Wiley & Sons. |

|Sapsford R, Abbott P (1992) Research Methods For Nurses and The Caring Professions. Buckingham, Open University Press. |

|© RCN PUBLISHING COMPANY 2000 |

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