Field Notes

A research diary was kept in which the researcher recorded observations after each contact with the participants. These observations were made to provide a back up in case the recordings of the interviews failed or were hard to

transcribe due to background noise, and to capture non-verbal communication of the participants. Observations about the preceding clinical encounter were also recorded along with a description of the interview setting and early thoughts on areas of interest that were emerging from the participants that guided the topics covered in subsequent interviews. The field dairy served to enhance the rigor of the study as a record of the research process and a reflexive account (Doucet and Mauthner 2012; Kingdon 2005) of the decisions made during the data collection and analysis process.

4.5.11 Data Analysis

The data used for analysis in phase three were the transcriptions of the interviews with the women at the three key stages in their pregnancy

journeys. The interviews were informed by the observation of their antenatal consultations and their diary entries. The hermeneutic phenomenological

approach as described in phase two was used in this phase as it again seeks to explore the lived experience, in this case of the women participants, valuing each of their stories in their ‘everydayness’ as they engaged with their chosen CMU for care during their maternity journey (Miles et al. 2013).

Each interview was audio recorded and transcribed verbatim by myself. Four postnatal transcripts were typed by an audio-typist and checked for accuracy by myself. The transcripts were returned to the participants to allow the opportunity to assess whether they felt the interviews had been transcribed accurately. Returning the transcripts to the women also enabled opportunities for continued communication with the women throughout the data collection period, encouraging continued participation and reminding the women about the use of their ‘aide-memoire’ diary. The opportunity was given for

participants to change the opinions and stories expressed in the transcript, add any further thoughts since data collection or to withdraw from the study if they wished at that stage.

The same qualitative data analysis techniques used in phase two of the study, were used as described in section 4.3.9. The steps used in the analysis

process are summarised by Taylor (2009 p.77).

1. Transcription of the interviews

2. Checking at each stage for accuracy with the participants

3. Immersion in the data by reading and re-reading the transcripts for each stage to get a sense of the whole

4. Note taking and continued systematic reading, stage by stage 5. Generation of issues by content analysis

6. Noting similarities and differences 7. Generation of broader categories

8. Establishing that categories cover all aspects of the interviews 9. Finalising categories

10. Generating themes and deciding under which themes categories belonged 11. Guarding against bias

12. Checking trustworthiness (going back to the participants with the themes).

4.6 Rigour

Reliability and validity are concepts used to measure the quality of research and the conclusions drawn in methodologies where instruments are used to test or measure responses from participants. Whilst it is important that they reliably provide accurate data to allow consistency of findings across differing situations and data, their applicability to CSR is limited. CSR, according to Yin (2009) can be used to explore phenomena or events in the precise, everyday context in which they occur, and help to understand links and pathways in how the maternity services provided at rural CMUs contribute to NHS

Scotland’s Quality Ambitions. Whilst a reliable instrument can be a valuable part of the information required, other sources of evidence are required to achieve the more detailed, holistic picture that can inform the required understanding.

The quantitative data were collected for this research from an adapted version of a validated instrument, a questionnaire used in national surveys (Redshaw

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and Heikila 2010). The validity of that instrument applies in those particular circumstances and this lends confidence for its use in this research, as the results will be comparable to the original survey. The same instrument (an Excel spreadsheet) was also used across both CMUs allowing consistency in the variables collected and the opportunity to provide comparisons, if required, between these (Appendix 1). Should this research be repeated using the same instrument to find out the same information, then it would be a valid and reliable instrument, but should the full CSR be repeated it would be unlikely that the same findings would be replicated throughout the study. The

boundedness of the case by time, as a snapshot of a particular period in the life of the CMUs, and the interpretive lens or background that the researcher brought to the interpretation would make similar findings possible but not necessarily the desired outcome of CSR (Thomas 2011).

The terms offered by some qualitative researchers as ways of establishing the rigour of a study appear to employ external measures applied once the study is completed (Ritchie and Lewis 2009) Credibility refers to the truth, value or believability of findings, dependability relates to the trustworthiness of the data presented and transferability is the extent to which the findings could be replicated in a similar setting (Creswell 2014). The dependability of this

research was addressed by ensuring that there was a transparent audit trail. This trail began with the original protocol, ethical and management

permissions, consent forms and associated documents and led to the

anonymised raw data transcripts, research diaries, spreadsheets and analysis summaries. These are clearly documented and available for verification at all times (Parahoo 2006), but the echoes of the terms, validity and reliability can be hard to reject as underpinning concepts. Morse et al. (2002) suggest that rigor is achieved by building validity and reliability measures into a study, as an intrinsic part of the research process, rather than relying on external measures on completion of the study. The verification strategies that they suggested to ensure quality and rigor include methodological coherence, appropriate sampling and concurrent data collection and analysis.

In this study, methodological coherence involved a constant awareness of the research question, the appropriateness of the sampling frame, the data

collection methods and the concurrent analysis in order to make appropriate changes and modifications, to maintain the focus on the aims of the case study research. Thomas (2011 p.66 - 68) summarises the criteria for indicating the quality of CSR as:

• Clarity of writing, terms consistently used, defined where necessary and well constructed.

• The problem or question being addressed being clearly outlined and sufficient rationale is used for its significance.

• Research methods adequately justified and chosen appropriately

• Sufficient information given about the research process and the researcher.

• Clarity of the evidence for the main findings

• Appropriateness of the selection of cases, data collection processes and analytical techniques.

• Contextual description for the study explained and justified.

• Rival explanations addressed and justifiable conclusions drawn.

As discussed within the philosophical framework and the qualitative data analysis sections in later chapters, I made transparent my presuppositions about the care provided by CMUs as an absolute prerequisite for the

credibility, transferability and dependability of this research.

The participants were asked to check initially the accuracy of their individual transcripts, and later the interpretation of early themes emerging from the study. As discussed in Section 4.7 regarding ethical and analytical issues, the views of one participant on the summary of my interpretation of the early themes arising from this research meant that a new understanding was reached (Dowling 2011). The dependability of the interpretation and

presentation of the findings were then addressed by the “phenomenological nod”, when the final description resonated with those who lived the experience (Oiler 1982 p.179).

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4.7 Ethical Considerations

Ethical considerations regarding the conduct of this study were focussed on encompassing protection of the dignity, rights, safety and well being of all the research participants. Beauchamp and Childress (2013) identify four principles that can be used to guide ethical responsibility and accountability in research practice.

4.7.1 Beneficence

Beneficence is defined by as:

“A statement of moral obligation to act for the benefit of others”’. Beauchamp and Childress (2013, p.203)

The principles of beneficence are identified as minimising harm and

maximising benefits (Polit and Back 2012). Beneficence concerns providing benefits to others whilst balancing the risks, benefits and costs to achieve the best overall results for all (Beauchamp and Childress 2013). The participants in this research were made aware that whilst there were no immediate benefits to themselves in taking part, they would be helping midwives and women in the future by contributing to research that aimed to inform service development and improvement. It was recognised that when the study was completed, the termination of involvement with the research may have caused or exacerbated any feelings of isolation, which could have been potentially harmful. Contact was maintained through asking the participants to check the transcriptions of their interviews and by requesting comments on the analysis summary as the study drew to a close. This allowed a gradual closure of their contributions whilst leaving communication for any further comments open for the participants for a final month after they received the summary.