Once the site was selected mechanisms for entry into the environment were sought. At the inception of this project, the researcher had a pre-existing curiosity about how certain social activities within the nurses’ shift impacted on the development of an individual nurse’s
professional identity. The clinical handover, and MDMs were chosen to be the main focus of this research project because they were seen to be the most appropriate arena for researching social elements within nursing (Kerr, et al., 2011).
Two participant observation processes were developed. The first was a traditional ethnographic method of the researcher being present in the setting as an instrument, observing note taking, and reflecting. The second process was a more innovative method whereby the participants’ were video recorded during their nursing group handovers, and MDM. Later, in the study these nurses became participant observers of themselves when they watched these recordings, and discussed them during the interviews.
The use of video created some unease from the ethics committee when this project was first submitted for review. Some members of the committee were apprehensive that the clinical competency of the nurse participants might be exposed during filming, and that this would not be in the interest of participants. Once the researcher explained that clinical practice was not, and could not, be assessed within this arena, the ethics on the project was approved.
49 | P a g e There were other practical concerns connected with the use of videorecording to collect data. It was imperative to obtain high quality video footage (for example, clear picture quality, and sound clarity). This issue was addressed when a technician from the supervisor’s unit was engaged to film the four handover sequences. This resulted in good quality video footage being obtained. There also needed to be acknowledgement of the possibility of the Hawthorne effect (Chiesa & Hobbs, 2008). This would almost certainly impact on the behaviour of the nurses, and allied health staff once they realised they were being videoed. This was, in fact, recognised by each of the videoed participant groups, some of who stated before filming that they felt
embarrassed about being filmed. Others said that they would be “on their best behaviour during the filming”. Despite these concerns, the researcher felt that the videos gave a relatively true picture of social elements of the handover, and MDM within the two units of study.
The healthcare organisation was the researcher’s current place of work at the beginning of the project. As a result, the organisational structure, and communication processes were fully understood by the researcher. Nursing has a clear hierarchy of communication, and therefore, permission to collect the data was sought through the appropriate staff within the organisation. Initially the Director of Nursing was approached to gain permission to undertake the research project. This was granted, and then the researcher approached the relevant Nurse Unit
Managers (NUMs) by arranging formal, one-to-one meetings. As the researcher was well known to both NUMs, they were keen for their staff to be involved in the research. The purposeful sampling frame was then defined after each NUMs identified the appropriate time when the nurse-to-nurse handover, and the MDM could be filmed. The scheduling identified that the nurse delivering the nurse-to-nurse handover would be the same nurse that would lead the MDM. Each NUM then reviewed the appropriateness of the skill-mix of staff that would be present for the video. The NUM or the nurse in charge discussed this with each of the staff that would be involved. At this stage the process of informed consent was discussed. Consent was obtained before the researcher was introduced to the staff. Each of the staff willing to
participate then filled in an informed consent. Most of the staff knew the researcher, and it was identified from the beginning that the researcher would in some way be a participant observer due to her knowledge of the context, and the nursing profession. Valid consent forms were signed by all participants. There was a positive response to the request to consent with all the regular unit staff being keen to participate.
Ethics was successfully obtained through the University of Melbourne Human Research Ethics Committee. Ethics was also sought from the healthcare organisation although this process proved to be a little more difficult, due to the both the use of ethnography and the insider perspective of the researcher. Both of these were unusual to the research commonly done
50 | P a g e within this clinical organisation. As a result entry into the research environment became a protracted process. Ethical approval from the healthcare network was finally obtained after twelve months. One of the concerns raised by the ethics committee was the issue of the insider of the researcher into the environment, and the small sample size. Much of the research in hospitals is driven by medical projects using scientific positivist methodologies, and so the members of these ethics committees are more familiar with this paradigm. This ethics proposal was relatively unusual particularly in its use of video recordings. It was viewed by the
committee through the same prism as other scientific projects, and therefore took some time to be understood within its own paradigm. It was not until advice was sought from one of the Medical Professors who understood the qualitative paradigm that the research was finally approved. From here entry into the environment was relatively straight forweard. Once ethics approval was obtained the practical entry to the environment was sought through talking to the Nurse Unit Manager. The nursing, and multidisciplinary staff were individually invited to voluntarily consent to participate by the researcher. The researcher was considered an insider, and well known, and the project was viewed by the participants as being relatively non-
intrusive to the nurses’ daily schedules.
Sampling and Recruitment
Fourteen nurses were recruited as participants. Known technically in the ethnographically literature as key informants, in this thesis they are referred to as the participants. These participants completed a questionnaire about their demographic, and nursing work, participated in the nurses’ group handover, and/or the MDM. In relation to observing the handover, and the MDM there were four groups -two handover groups, and two
multidisciplinary groups. Ten of these participants were interviewed either individually or in focus groups. In addition, there were eight other qualified health professionals, and five students who consented to be video recorded during the group handover, and/or the MDM. These people were not recorded as participants rather they formed part of the cultural environment in which the research took place. These are depicted in Tables 4, and 5.
The ten participants who were interviewed either individually or in focus groups all looked at, and reviewed the video recordings of the meetings they had been involved in. Four nurses from the nursing group handover were involved in the individual interviews. Two of these nurses were additionally interviewed individually in relation to their MDM involvement. There were two focus groups. One group comprised of four nurses, and the other comprised of two these related to nursing group handover.
51 | P a g e 1Table 4: Nurse Handover, and MDM Composition
Unit A
Handover Unit B Handover Unit A MDM Unit B MDM Presenter ANUM from
morning shift ANUM from morning shift ANUM from morning shift ANUM from morning shift
Motivator
(the participants that motivated the team and dominated the conversations) Presenter & ANUM for oncoming shift Presenter & ANUM from oncoming shift No one
motivator No one motivator
Group Members ANUM presenter ANUM for oncoming shift CNS x1 RN x1 Graduate nurse (Junior) ANUM presenter ANUM for oncoming shift RN x5 EN x1 Graduate nurse (junior) Nursing students x2 ANUM Physio, pharmacist, OT, social worker ANUM Physio x2 OT x2 Physio students x 2 OT student x 1
Table 5: Summary of the Data Collection
Handover Multidisciplinary team meetings Method Video recording meeting Video recording meeting
Unit A
Participant (1) delivering handover Unit A Participant (1) participating in team meeting
Unit B
Participant (2) delivering handover Unit B Participant (2) participating in team meeting
Method Interviews Interviews
Unit
A Interview with participant (1) reviewing video recording of both handover, and multidisciplinary team meeting Unit
A Interview a nurse who attended the handover Unit
B Interview with participant (2) reviewing video recording of both handover, and multidisciplinary team meeting Unit
B Interview a nurse who attended the handover
1 • ANUM = Associate Unit Manager
• CNS = Clinical Nurse specialist • RN = Registered Nurse • EN = Enrolled Nurse
52 | P a g e
Method Focus Group
Unit
A Group from Unit A to undertake a focus group Unit
B Group from Unit B to undertake a focus group