Member checking: Throughout the data collection and analysis process, two patient advisory groups were asked to comment on the credibility of initial researcher interpretations of participant views on respect and what was missing. Two committee members also engaged in a 4-hour analytic review of the data analysis and emergent themes as a form of member checking the analysis. Moreover, and following the
75 procedures of grounded theory I relied on discussions with colleagues to test concepts and theories under development.
The call for a new way of describing humanistic qualitative research has received prominence recently (Cheshire, 2016; Lather & St. Pierre, 2013). Cheshire emphasizes the tension between qualitative inquiry and the scientific structural concepts that frame qualitative research (Cheshire, 2016). The question is discussed as to how qualitative researchers can ensure that the rigor of the research is demonstrated without using quantitative, positivist terminology? The author concludes by demonstrating qualitative rigor with such criteria as: credibility, the trustworthiness and plausibility of the research findings (Cheshire, 2016). Charmaz also lists credibility among her criteria for evaluating a grounded theory study (Charmaz, 2014). To this criterion I have added transferability.
Credibility: To establish trustworthiness of the data or credibility, I engaged directly with participants in situ where their clinical encounters took place. The credibility of the data was derived from verbatim transcriptions of video-recordings of the encounters. The closeness of the researcher to participants in the field contributed to the accuracy of the data in the study. Moreover, the degree of time spent in the clinic and with individual participants was akin to Pink and Morgan’s description of a focused ethnography
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‘characterized by forms of intensity that lead to deep and valid ways of knowing’ (Pink &
Morgan, 2013). The authors go on to reflect that during the analysis phase of a VRE study, there is continued ‘depth and immersion’ in the data (Pink & Morgan, 2013).
Throughout the study, I continuously engaged in personal reflexivity to document how I believed I influenced the co-creation of data and to reveal research biases and assumptions. Finally, the results are substantiated with examples of text from the data and where possible video-recordings themselves to demonstrate that the emerging description is an accurate portrayal of participant’s perspectives.
Transferability: According to Strauss and Corbin (1990), the more abstract the concepts, the more applicable they are. Once the conditions under which respect occurs are specified, then others (practitioners, health systems, policymakers) may apply the theory in similar situations (Strauss, 1990). To ensure the transferability of the methodology used, detailed descriptions of the video-reflexivity method and grounded theory analysis are provided, particularly the contextual factors such as location and participants as well as the conditions under which certain concepts were observed. The results of this study will be transferable to other health systems that share similar conditions as those of the primary care internal medicine clinical settings in this study.
77 3.8 Positionality: The researcher and the research
In qualitative studies, researchers are often aware that their experiences, views, beliefs and attitudes cannot be separated from the research (Charmaz, 2014; Cheshire, 2016; Lather & St. Pierre, 2013). As such, researchers engage in their own reflexive processes to constantly be aware of their reach into the research (Carroll & Mesman 2011; Collier & Wyer, 2016). In the interests of transparency, I reveal to the reader my life experiences, beliefs and attitudes toward respect so that the readers may judge for themselves how these may influence the research study. My approach to most social and political contexts is grounded in my early childhood experiences growing up on a small island that is easily described as a low to middle-income developing country. First-world luxuries remain a wonder, none more so than in the area of healthcare. I am a social democrat who believes in the universal right to healthcare and I embrace the notion that health is a basic human right. My early career was centered in the world of diplomacy and development and I continue to subscribe to the philosophy that we should do whatever we can for those around us to achieve their highest potential. I am also a daughter, mother and wife, to whom family is fundamental. The research is being undertaken in the context of managing these competing demands and this is being shared for no other reason than to let the reader know that the research study is one of a plethora of activities that I am engaged in.
78 As part of positioning myself as researcher in the study, I continuously engaged in researcher reflexivity and memoing. Being privy to others’ clinical encounters was cause for much personal reflection. Over time my familiarity with primary care and the relationship between patients and clinicians has been awe-inspiring. The depth of the relationship and its influence on the care received undoubtedly frames the context within which respect emerged in the encounter. I was reminded on numerous occasions how intimate the relationship between patients and clinicians is when patients cried and used such language as ‘devastating’ to describe the loss of a clinician; how deep the relationship is when one elderly patient lamented that her physical limitations prevented her from ‘seeing her two best friends’ who she visited with twice a week for over 50 years and in the same conversation described her clinician ‘like my best friend’. It was especially uncomfortable for me to be in the room when such personal conversations as a participant’s sexual functioning was discussed at length, when a participant underwent cognitive testing for dementia for the first time and when a participant declined to participate because they did not want me to record or witness the discussion of their history with their clinician which included a long journey and many canceled appointments. I realized how privileged I am to be a part of their healthcare experience, to be able to share, record and revisit with them these intimate moments and it highlighted for me as researcher how important respect is to the research as well and how
79 respectful VRE is as a methodology as it gives the participants control over when recording occurs and what is recorded.
While I undeniably affected the generation and interpretation of the data in this study, it should also be noted that in a VRE study the researcher and participants develop novel data by engaging with each other. The reader also has a unique way of interpreting the results of the study, which may differ from the researcher, and which should also be taken into account.
3.9 Summary
This research is a qualitative VRE study. VRE was used to generate a description of the characteristics of respect in the clinical encounter according to patients and clinicians. This is a novel approach, as the use of Video-Reflexive Ethnography is relatively new in the United States and there is a dearth of literature on a description of respect grounded in participants’ perspectives. Involving patients directly in VRE studies is also relatively new (Collier & Wyer, 2016) and is in keeping with calls for greater collaboration with patients on patient centered research. A further analysis was done to see whether the descriptions of respect are related to shared decision making in the encounter. The results of this analysis may inform policymakers of the characteristics of respect described by participants in the encounter themselves, that are impacting the quality of shared decision making healthcare delivery.
80 Chapter Four
Results
The data described in this results chapter emerged from twenty-seven individual one-hour video-reflexivity sessions with fourteen clinicians, thirteen patients and three caregivers. Three of the video-reflexivity sessions were conducted with both the patient and their caregiver, both of whom had also participated in the clinical encounter together.
I drew on participants’ own words describing what respect means to them. The various participant descriptions of respect were qualitatively analyzed and resulted in four analytical descriptions of respect: valuing individuality, valuing agency, valuing feeling comfortable, and valuing partnership. The results are presented according to the three research questions:
Research Question 1: How do patients describe respect in the clinical encounter?
Research Question 2: How do clinicians describe respect in the clinical encounter?
Research Question 3: How is respect related to shared decision making?