Because of limitations of space it is not possible in the Results chapters to demonstrate how the categories and their properties developed over the period of data collection and analysis. Nor is it possible to give any more than illustrative quotations from the data itself as corroborative evidence for the results presented. However in this part of the chapter on Research Methods it is proposed to offer a rather more detailed explanation of the emergence from analysis of a single category. This is an example of the process which was
followed with all the other categories described in the Results chapters. The category described is one of the Area 4 categories, (Category D2 - Support) referring to the nurses' intentions when they intervened to try to calm the patients. Category Title: SUPPORT
Definition: To induce a patient to interpret that a nurse supports and cares about him.
The process of analysing the data began with the written accounts of the nurses. The questionnaires were analysed sentence by sentence. Initially almost every line required a new descriptive category, but soon it became possible to use existing categories to code many subsequent data items. The process of initial category development can be seen from extracts from Questionnaire Two. The student nurse who described the incident was dealing with a pregnant woman accompanied to hospital by her husband. The couple had just been told that their baby had died in utero and were understandably very distressed. The nurse's sentence by sentence account is shown below in italics, followed by the codings in capital letters (the full list of codes is given in Appendix 3)
"When the patient arrived on the ward, I tried to appear friendly and calm."
CODE Cl.4: ADOPTS A CALM AND FRIENDLY MANNER "I held her arm as I was taking them to their room."
CODE Cl.l: USES TOUCH
"I sat alongside her on the bed, / asking questions about their family, letting them get round to mentioning this pregnancy."
CODE Cl.2: SITS OR MOVES CLOSE TO THE PATIENT CODE C2.1: ASKS QUESTIONS
"I offered the services o f the hospital chaplain which they accepted." CODE C2.3: SUGGESTS, ADVISES OR TELLS THE PATIENT
WHAT TO DO
"I went back in and talked about what the doctor had planned,/ encouraged them to ask questions / and made sure they knew that if they wanted a nurse, how to get one with the call bell or come to the nurses' station."
CODE C3.2: GIVES INFORMATION ABOUT TREATMENT CODE C2.3: SUGGESTS, ADVISES OR TELLS THE
PATIENT WHAT TO DO
CODE C3.4: GIVES INFORMATION ABOUT THE WARD ENVIRONMENT
"Physical contact - I held her arm and hand but felt that as her husband was there, he was very supportive and she didn't need me as much as I thought."
CODE Cl.l: USES TOUCH "I gave them a box o f tissues."
CODE C4.1: GIVES PRACTICAL HELP
"After the patient had the termination she said that my silent care and concern on her arrival had helped far more than the busy-ness o f staff in the clinic."
CODE E.1: PATIENT BECAME CALMER THAN BEFORE
The initial categories, as shown here, were attempts to describe as directly as possible the actions mentioned in the incidents. However, as more data built up, it became apparent that these categories were inadequate to describe fully what was occurring. For example, many uses of touch appeared in Category 1.1. In
Questionnaire Two the nurse appeared to be using physical contact to try to support and calm the patient. However, in other questionnaires the nurses stated that they touched patients in order to distract their attention from their fears. In another case a nurse held a patient by his shoulder in order to restrain him from leaving the ward. All were reliably coded as C l.l USES TOUCH, but the category appeared to be concealing important differences in the way touch was being used.
It was while searching for a way of bringing out these differences that the researcher first came upon Sperber & Wilson's (1986) Inferential Model of Communication. The inferential model highlighted the fact that communicative actions cannot be fully understood outside the context of the communicator's intentions. Therefore a higher-level set of explanatory categories was developed from analysis of the different types of intention revealed in the data.
Four Intentions Categories were developed as follows: PREDICTION
DISTRACTION PATIENT CONTROL DIRECT ACTION
Prediction is defined as inducing the patient to predict that he will be safer than he fears. Distraction occurs when a nurse induces a patient to move his attention away from a topic of concern. Patient control is an attempt by a nurse to induce a patient to control an aversive situation for himself, while Direct Action occurs when a nurse tries to control an aversive situation for a patient.
At the same time as these new explanatory categories were being developed, the interviews with patients were proceeding. Problems occurred when trying to code some of the material from these interviews: one of the passages which did not
seem to fit into any of the four Intentions categories was a patient's description of how a nurse helped to calm her before an operation:
"And this very junior nurse came and she just sat on the edge o f the bed, and took my hand, and she said, 7 know it's difficult but is there anything I can do to help you, to make you feel better?’ And it really was tremendously comforting. Calming. The fact o f the touch, the fact o f the concern in her voice, the fact that she made eye to eye contact, and the fact that she didn't appear too rushed were all very reassuring." (P50, 2)
The existing intentions categories did not seem to fit this incident. The closest category seemed to be Patient Control, because the nurse invited the patient to name any way in which she could help. However, the patient's account concentrates on the fact that the nurse took time to show concern, using touch, voice and eye contact to demonstrate how concerned she was about the patient. In other words, the nurse's intervention appeared to achieve its calming effect in a different way from that described by any of the four intentions categories. In the theory memos written at this time the term "Relationship-Building" was coined as a working title for a new category developing out of this material. The literature suggested that relationship-building was important in reassurance and a reading of Bowlby's (1971) work on Attachment appeared to offer an independently-developed theoretical framework for the concept. The questionnaire and interview data were reviewed and tentative codings were made. Many non-verbal actions, such as "using touch" frequently appeared to be associated with the Relationship-Building category, as did most of the expressions of optimism or understanding.
When trying to develop the properties of this category, theory memos were written which questioned the extent to which the relationship between the nurse and patient must inevitably be two-way. Incidents were noted where two-way emotional ties certainly existed and played a powerful part in interactions. However, in other incidents the contact between nurse and patient was relatively
brief and the relationship was one-way, in the sense that the patient was almost wholly dependent on the nurse. Therefore one of the properties of this category established by this method was that successful incidents could be one-way interventions. This led the researcher to question whether the word "relationship" was adequate to describe one-way interventions.
By this time it was also apparent that the title "Relationship-Building" was unsatisfactory because it was not couched in inferential terms. It summarises nurses' actions, but it does not state how the nurses intended the patients to respond. The cue to a more satisfactory title appeared on re-examination of some questionnaire data, tentatively coded under the relationship-building heading. A nurse reported that: "Because she (the patient) was nervous, I held her hand" (Q3). Here the nurse seemed to be trying physically to transmit support or caring through use of touch. In the theory memos a number of category headings were proposed to convey this idea:
- Inducing the patient to experience a feeling o f attachment. - Supporting the patient emotionally.
- Getting close to the patient physically and emotionally.
However, the title which seemed to fit the data most clearly was: Inducing the patient to believe that the nurse supports and cares about him. This was adopted as a tentative category heading to replace "relationship-building". The question then was whether "Support" as defined above could stand as an independent intervention, or whether it always needed to be associated with one of the other four intentions categories. Closer examination of the data made it apparent that the nurses themselves believed that interventions using Support could have an independent calming effect. Thus a nurse noted in one of the questionnaire incidents:
"I don't think what I SAID had any real effect on him. The assurance he gained, came from already having someone to talk to. It was being there that seemed to help him to see things in a better light. Another person who cared enough about him to ask about his well-being and
show concern in his Juture health." (Q101)
Therefore the Support category could stand alone and, with its addition to the other four intentions categories, all the relevant data on intentions appeared to be reliably codable. Analysis then moved on to re-examining all the data thus coded, in order to establish the detailed properties of this new category.
This method of category development was employed in each Area of the classification scheme. Once the categories were established and data could be coded reliably, attention moved to establishing the detailed properties of each. The final stage in the process was the development of higher-level theory with explanatory and predictive power, which integrated the range of descriptive categories.