ACCESS, NEGOTIATION AND SAMPLING TECHNIQUES

Permission to conduct research at hospitals in South Africa is a tedious process that requires a lot of paperwork and patience on the part of the researcher. Recruiting, specifically patients, can be difficult at public health-care facilities owing to the nature of procedures and processes at clinics. The actual processes of recruiting patients and ethical considerations are discussed below.

6.7.1 Permission to conduct case study research at Stanger Hospital’s diabetes clinic

Permission was obtained from the following bodies/people in order to conduct research at Stanger hospital’s diabetes clinic:

• The University of South Africa (Unisa), Department of Sociology Ethics Committee.

• Stanger Hospital’s CEO, Ms RT Ngcobo.

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• Ilembe Health District Municipality manager, Ms S Dube (since the hospital was located within the geographical district of the Ilembe municipal area).

• The Department of Health in KwaZulu-Natal, chaired and managed in the sub-component Health Research and Knowledge by Dr E Lutge.

6.7.2 Sampling procedures and recruitment of the research participants

The two sampling techniques that were used to recruit participants for this study included purposive and convenience sampling. According to Keyton (2015:115), convenience sampling “selects those people who are convenient to locate and identify as potential respondents”. For this study, patients who received health-care at the diabetes clinic and were willing to participate were conveniently selected, provided they fitted the inclusion criteria.

Purposive sampling was used to recruit patients for the study. According to du Plooy (2009:123), “where previous knowledge leads to a purposive sample being drawn that can guarantee the inclusion of certain population parameters (or characteristics), it would be termed a purposive quota sample.” For this specific study, patients needed to fit certain inclusion criteria (population characteristics) and were therefore purposively selected. Neuman (2007:142) indicates that purposive sampling needs to be used in a situation where the researcher has a specific purpose in mind and is thus judgemental in selecting cases. Neuman (2007:142) further indicates that

“purposive sampling occurs when a researcher wants to identify particular cases for in-depth investigation. The purpose is less to generalize to a larger population than it is to gain a deeper understanding of types.”

Difficulty was experienced in recruiting patients for the study. Consultation at the clinic was not by appointment, but conducted on a first-come, first-served basis which often resulted in a long waiting period for patients. Hence patients arrived early at the clinic to receive treatment and then waited and would then rush away after they were examined to attend to their personal day-to-day matters. The nurses allowed the researcher to introduce herself to the patients on Tuesdays but patients

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were reluctant, preferring to consult with the doctor and leave instead of being interviewed with the possibility of missing their turn in the queue to see the doctor.

The medical doctor consulted only once a week on a Tuesday, making this the busiest day at the clinic. Patients waited in long queues before they were attended to. Therefore only a few patients could be recruited in the first week of the fieldwork process, with the majority recruited during the second Tuesday at the clinic.

According to Taylor, Faden and Kass (2010:450), “the object of study in clinical research is generally a particular disease state or process. Potential patient-subjects are selected because they have characteristics that are relevant to the disease process under study, not because they are members of a particular community.” The staff nurse assisted with recruiting of English-speaking patients as per the inclusion criteria for the study. The staff nurse was more of an insider to the patients since she had treated them over a long period of time and they trusted her more than the researcher. Also, the staff nurse reassured the patients that they would not miss their turn in the queue if they took part in the study. The staff nurse briefed the patient about the research in the presence of the researcher and requested if they would like to participate in the study voluntarily. The assistance provided by the staff nurse in the recruitment of the patients was in no manner biased in selecting patients that would praise services or indicate effective communication in order to please the nurses. Instead, these patients took part in the research because of their fluency in English, diabetes diagnosis and willingness to be part of the research process.

Purposive sampling makes provision for such assistance in the recruitment of participants. The staff nurse adhered to medical ethics which dictates integrity.

According to Kumar (2011:212):

“as the main aim in qualitative enquiries is to explore the diversity, sample size and sampling strategy do not play a significant role in the selection of a sample.

If selected carefully, diversity can be extensively and accurately described on the basis of information obtained even from one individual.”

The inherent nature of this study was to analyse communication dynamics at the diabetes clinic. Qualitative research studies, specifically case studies, are conducted to obtain in-depth analysis in contextual settings. Therefore diversity, as opposed to sample size, was the focus of this research since the study did not aim to make any

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generalisations. Instead, the outcome was to gain an understanding of the different aims of the study. Thus a sample of 15 patients and seven HCPs was considered sufficient to obtain depth and richness in data.

6.7.2.1 Sample sufficiency/sample size and data saturation as applied to the case study

According to Mays and Pope (1995:109), “it is said that qualitative methods tend to generate large amounts of detailed information about a small number of settings”.

Data saturation was achieved after the indicated number of interviews had been conducted with the HCPs and patients during the case study undertaken at Stanger Hospital’s diabetes clinic.

Data saturation was reached when replication started occurring in the data collected.

The study had a strong theoretical underpinning and the data was therefore substantiated with a strong theoretical grounding as explained in the findings of the study (see chapters 7 and 8). According to Silverman (2010:144), sample sizes in qualitative research are often saturated according to the theoretical foundation of the study (as discussed in the literature review chapters). When data redundancy occurs or theoretical saturation occurs, then sufficient time has been spent in the field (Lincoln & Guba 1985). Hence irrespective of the amount of time spent in the field, if a researcher encounters data saturation, the fieldwork process is complete. This pertains to the research questions 2, 3 and 4 which are related to data collection specifically, since some research questions (example, research question 1) are also related to theory (see chapter 1). Theoretical saturation enables researchers to link or generalise findings to the theory as opposed to the sample or units of analysis selected for the study. This was the case in this study as it was focused on obtaining an understanding of communication dynamics as it occurred in the medical system and to link findings obtained to the theoretical propositions as opposed to generalising the findings to the entire clinic population. Yin (2014:42) defines this process as analytical generalisation, which is grounded on the design of the case study and empirically enhanced by its findings, which in turn is based on theory or theoretical propositions.

Kumar (2011:212) explains that qualitative researchers, unlike quantitative researchers, do not have a sample size in mind. Bearing this in mind, both these

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research designs obtain a sufficient sample size once data saturation has been reached. While quantitative research is usually guided by a random sample because of the nature of the design, qualitative research is guided by the researcher’s judgement to select a sample that will provide the “best” information. Kumar (2011:213) defines data saturation as “a point where you are not getting any new information or it is negligible. This stage determines the sample size”. Kumar (2011:213) also notes that the saturation point is more applicable to data collection strategies which occur on a one-to-one basis as in the case of this study since in-depth, individual interviews were conducted with both HCPs and patients.

Saturation occurred after the first ten interviews were conducted since the researcher noted that no new information was obtained after the first ten patients.

However, the researcher continued to interview another five patients for further verification. No new information was gleaned from these patients. Regarding the HCPs, the researcher aimed to interview all the HCPs employed at the diabetes clinic at the time the research was conducted.

According to Ritchie, Lewis, McNoughton and Ormston (2014:117), the following four reasons substantiate the use of small or sufficient sample sizes, in qualitative research:

• If data is properly analysed, very little new information will become available from additional fieldwork units. According to Ritchie et al (2014:117), “this is because phenomena need only appear once to be part of the analytical map.

There is therefore a point of diminishing return where increasing the sample size no longer contributes to new evidence.” As indicated above, after ten interviews had been conducted, data saturation occurred, although the researcher conducted a further five interviews.

• Since qualitative research is not focused on statements about incidence or prevalence, there is no requirement or reason to provide statistics or estimates in relation to variables.

• Qualitative research yields rich detailed data, thus although “there will be many hundred ‘bites’ of information from each unit of data analysis, sample sizes need to be kept to a reasonably small scale” (Ritchie et al 2014:117).

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• Finally, qualitative research involves lots of hard work and time invested by the researcher. It is not possible to conduct hundreds of in-depth interviews as well as years of observation unless the researcher is conducting a longitudinal study.

Adhering to the reasoning stated above and the case study approach to research, a sufficient sample was selected to analyse the different units of analysis/units of observation for this case.