Data collection

5.6.8.1 The case-study protocol

A case-study protocol was developed (see Appendix 8) and used to help plan the case-study and anticipate any issues (Yin 2014). The reliability of a case-study is enhanced by the development of a case-study protocol to guide the researcher and keep the case-study focused (Yin 2014). The use of a case-study protocol is considered to be crucial when using a multiple- case design (Yin 2014).

The case-study protocol provided an overview of the aim, objectives and theoretical framework for the case-study and described the data collection procedures and questions, increasing the reliability of the case-study (Yin 2014). The data collection procedures identified the contact details for doing fieldwork at the case-study sites and described the data collection plan. The data collection plan specified the type of evidence: the events to be observed, participants to be interviewed and the documents to be retrieved (see Appendix 8). The data collection questions are the case- study questions, to guide the line of the enquiry and should not be confused with the questions being asked of participants. The data collection

questions should be in the forefront of the researcher’s mind when collecting data to keep the case-study focused. Each question should identify a list of possible sources of evidence.

The case-study protocol should firmly distinguish between: level 1

questions, those posed to interviewees in each case (university and NHS Trusts): level 2 questions which are the broad questions of inquiry for the individual or single cases and Level 3 questions those asked of the pattern of findings across multiple cases (Yin 2014).

5.6.8.2 Use of in-depth interviews in case-study research

In-depth interviews are frequently used in case-study research and are invaluable sources of evidence (Stake 1995; Yin 2014). In this study, in- depth interviews were considered to be a central data source for exploring nursing students’ learning and understanding of aseptic technique from multiple views and perspectives of the case (Stake 1995). This allowed nursing students’ learning of aseptic technique to be explored from the

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perspective of the student, those that teach and supervise students in university and clinical practice and experts in infection prevention and control. In-depth interviews gave participants the time and capacity to provide an account of the issues that were important to them (Green and Thorogood 2014). The meaning of the term ‘aseptic technique’ and different participants’ knowledge and understanding of aseptic technique could be investigated for the first time within the same study. In-depth face to face interviews were originally planned but changed to telephone interviews following the selection of case-study sites after phase one of the study. Telephone interviews were considered to be more viable on the basis of experience of conducting phase one.

5.6.8.3 Telephone interviews in qualitative research

Telephone interviews have been positively evaluated for allowing expansion and comprehensiveness in social research (Bryman 2016). However, there is limited research into the use of telephone interviews in qualitative research (Irvine 2010; Bryman 2016). Telephone interviews in qualitative research can be more cost-effective than face to face interviews (Irvine et al. 2012b). The shortcomings of telephone interviews are the inability to pick up on non-verbal cues, develop a rapport, and sustain interaction and possible loss of contextual data (Irvine 2010; Irvine et al. 2012b; Trier-Bieniek 2012).

The choice of whether telephone interviews are used instead of face to face interviews should be determined by the line of enquiry, information to be gained, participants to be interviewed and data analysis to be undertaken (Irvine et al. 2012a). Interviewing participants about nursing students’ learning of aseptic technique was not likely to be highly sensitive for

individuals. The need to pick up on non-verbal cues was not seen as crucial to the line of enquiry. Telephone interviews were therefore not considered to be detrimental in weakening the study.

5.6.8.4 Interview Guide

An interview guide was developed (see Appendix 9) based on the literature review and phase one findings. The interview guide was informed by the phase one findings and this was another connecting point between the quantitative and qualitative approaches used (Ivankova et al. 2006). In

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case-study interviews it is recommended that a small number of issue focused questions should be prepared ahead to limit veering from the case- study protocol (Stake 1995; Rubin and Rubin 2011). Questions were formulated in the interview guide (see Appendix 9) to ensure appropriate phrasing of questions.

The questions were informed by the theoretical frameworks underpinning the study. For example, the interview questions asked about nursing students’ learning of aseptic technique in the different ‘Communities of Practice’ (Wenger 1998) in university and clinical practice. Another question asked about the transfer of aseptic technique from the university setting to clinical practice conceptualising these as distinct ‘Communities of Practice’. The influence of role models in university and clinical practice was not directly asked, to avoid leading participants to answer in a particular way. However, by asking participants about what may influence nursing

students’ learning of aseptic technique in the university and clinical practice setting, there was opportunity to discuss role models if desired. This is an example of how Social Learning theory (Bandura 1977) was considered during the development of the interview questions.

5.6.8.5 Pilot interviews

Pilot in-depth telephone interviews were conducted with a student, mentor and nurse educator to run through the interview process and check the interview guide (Braun and Clarke 2013) (see Appendix 9). The student, mentor and nurse educator were from the researcher’s own university and not from one of the case-study sites. Data from the pilot interviews were therefore excluded from the study. The pilot interviews allowed the researcher to practise their interview technique and test the interview questions and recording equipment (Berg and Lune 2014). No issues were encountered with the interview guide or recording equipment. During the first interview, permission to record the telephone interview was initially asked after the introduction but was subsequently changed to the beginning of the telephone call, to capture any background information about the participant. When asked about the underlying principles of aseptic

technique, many participants experienced difficulty in answering and sought clarification about what was being asked. The question often had to be re-

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phrased to ask ‘what rules they might apply when undertaking an aseptic technique?’ to obtain a response.

5.6.8.6 Conduct of the in-depth interviews

All interviews were conducted by telephone and digitally recorded for transcription. The interviews consisted of five phases: 1) introductions - self and research 2) interview brief 3) beginning the interview/warm up 4) during the interview questions 5) closing the interview (Ritchie et al. 2014) (see interview guide in Appendix 9). A friendly and non-threatening manner was used to develop a rapport with interviewees and gain trust. The degree of structure permissible in in-depth interviews will depend on the

epistemological position of the researcher and the extent of knowledge upon the given topic (Ritchie et al. 2014) Given the scarcity of knowledge and understanding in this area and the previously stated epistemological stance for this phase of the study, a flexible and exploratory approach was taken.

The interview guide provided structure but was used flexibly (King and Horrocks 2012). The order and phrasing of questions were not always identical to that of the interview guide. The questions were adapted to be sensitive to issues from the perspectives of different participants. A balance was struck between the interviewer guiding the interview to cover important issues and providing interviewees with the opportunity to explore their own perspectives, allowing unanticipated issues to emerge. Open ended questions were used to encourage discussion and exploration of the

issues. Probing was used to demonstrate responsiveness as an interviewer and to elicit greater detail, information and explanation (Ritchie et al. 2014). There was the potential threat of students perceiving a power balance between themselves as students and the researcher being a lecturer. There was also a risk of coercion and students providing social desirable responses to meet the lecturer’s expectations. This was minimised by students not being from the same university where the researcher worked. Students were also reminded at the beginning of the interview, that the interviewer should be seen in the capacity of a researcher rather than a lecturer. Some infection prevention and control nurses and one mentor

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from one NHS Trust were known to the researcher. This could not be predicted as it was dependent upon who agreed to participate in the study.

5.6.8.7 Documentary evidence

Documentary evidence from the two case-study sites: universities and NHS Trusts were collected. Documents assisted in corroborating the evidence from other data sources in the case-study (Yin 2014).

The researcher had insight into the type of documents that might be acquired from universities from their role as a lecturer. Documentary evidence requested from universities included lesson plans, student

information, assessment documents, teaching presentations and materials. These documents helped to corroborate the findings from interviews and observations about what and how aseptic technique is taught and assessed and what is learnt.

Advice was sought from research supervisors with a background in infection prevention and control and an infection control specialist nurse regarding infection prevention and control documents. Current infection policies/guidelines and infection control audits including hand-hygiene audits were retrieved from infection prevention teams where possible. Infection rates for Clostridium difficile, meticillin-resistant Staphylococcus

aureus (MRSA) and meticillin-sensitive Staphylococcus aureus (MSSA)

bacteraemias for each NHS Trusts were accessed from the public health websites in the respective country. Teaching presentations used in the education and training of health care professionals in aseptic technique were obtained. These sources gave contextual information about infection prevention and control practices in the NHS Trusts.

Any documentary evidence which might clarify the nature of the relationship between the university and NHS Trusts was requested. For example, minutes of meetings or memorandum of agreements might provide insight into communication and partnership working between the universities and NHS Trusts. Role descriptors might indicate joint roles and responsibilities for infection prevention education across university and NHS Trusts.

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5.6.8.8 Observation of teaching

Observation of aseptic technique teaching sessions in university was planned at both case-study sites. Observation methods was chosen for permitting the examination of behaviour and activity in the real life, natural setting of the classroom (Morgan et al. 2017). The purpose of observing teaching sessions was to gain greater insight into what and how pre- registration nursing students learn aseptic technique and are taught and assessed within the context of the ‘community of practice’ in university. Observation of teaching gave the opportunity to observe role models for aseptic technique in the university setting. Any teaching session where aseptic technique was taught or practised in an invasive or non-invasive clinical procedure was targeted to be observed.

There are two types of observation: participant observation, where the observer participates in activity and non-participant observation, where the observer is not involved (Hammersley and Atkinson 2007; Morgan et al. 2017). Non-participation observation was undertaken in teaching sessions to ensure that interaction or teaching was not compromised by the

involvement of the researcher. Participant observation was undertaken as a simulated patient in an OSCE assessment at case-study two. This

approach was used to make sure that the researcher’s presence was not intrusive and did not impact on the examination process.

The influence of being directly observed and observer bias are two major concerns in using observation (Swanwick 1994; Morgan et al. 2017). There may be different levels of awareness of observation taking place and the presence of the observer as a researcher might change behaviour, commonly known as the Hawthorne effect (Roethlisberger and Dickinson 1939; McCambridge et al. 2014; Morgan et al. 2017). The Hawthorne effect in research and in studies of infection control practices such as hand- hygiene has been the focus of much attention (Adair 1984; Diaper 1990; McCambridge et al. 2014; Gould et al. 2017b). Observer bias, is where an observer has their own perceptions and judgements about what is

observed and therefore true objectivity is widely regarded as unachievable (Morgan et al. 2017).

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A semi-structured observation schedule was developed based on the literature, phase one survey findings and theoretical propositions of the case-study (see Appendix 10) to keep the researcher focused and consistent in their approach to observation. Unstructured, participant observation is usually associated with qualitative approaches whereas structure, non-participant observations with quantitative approaches (Punch 2014). Unstructured observation typically does not employ an observation schedule for recording of behaviour (Bryman 2016). The level of structure in observation can vary like other data collection methods such as

interviews (Punch 2014).

In this study, semi-structured observation was undertaken using an observation schedule combining the strengths of both structured and unstructured observation. Structured observation was undertaken of what was being taught and assessed about aseptic technique and how. The behaviour of educators and students was observed (Punch 2014). This was complemented with more general information about how learning of aseptic technique in these universities was organised.