Methodological choice for study 1

Study 1 addressed the first two research questions (see 2.9). Bowers et al. (2006) suggests that quantitative research may be broadly classified into observational or experimental studies. Experimental studies involve the allocation of subjects to receive a treatment, service or experience whilst observational research involves active observation, without intervention, of treatment or care (Bowers et al., 2006). Observational studies can be sub- divided into descriptive and analytic with the latter involving a comparison of groups (Bowers et al., 2006). Observational research designs may be classified as cross-sectional, cohort or case-control studies (Bowers et al., 2006). Cross- sectional designs involve data collection from a specific point in time as

opposed to longitudinal studies (cohort or case control studies) which follow study participants over a period of time (Abramson and Abramson, 2011; Bowers et al., 2006). Types of analytic experimental and observational study methodologies are shown in figure 14.

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Figure 14: Analytic study methodologies (Song and Chung, 2010 fig.1 p9)

Denscombe (2014) suggests that five conditions need to be met in order for experimental research to be selected as the most suitable approach (see table 12).

Table 12: Conditions where experimental research is most appropriate

• Explanatory (and not exploratory) research • Well established body of knowledge exists

• Existing knowledge should allow formulation of research hypotheses • Observations produce numeric data which can be statistically analysed • Ability to implement controls over factors studied

(adapted from Denscombe (2014).

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The lack of an established body of knowledge on delay supports the view that experimental research is not indicated; descriptive research methods are appropriate when answering the question ‘what is going on’? (de Vaus, 2001). However, for the question regarding the effectiveness of AKCs it could be argued that experimental research would be appropriate. The randomised

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controlled trial (RCT), a form of experimental study, is regarded as the pinnacle of research or ‘gold standard’ when assessing the effectiveness of an

intervention (Polit and Beck, 2012; Lock and Nguyen, 2011; Robson, 2011; Eccles et al., 2003). Robson (2011 p99) contests this suggesting that reliance on RCTs as the sole criterion for scientific rigour ‘detracts from the main

question when one is assessing an inquiry….; has the overall case made by the investigator been established to a degree that warrants tentative acceptance of the theoretical or empirical claims that were made’? Experimental research has also been criticised as it does not capture service inputs which may contribute to outcomes in natural settings (Bowling, 2014; Blaxter, 2010) and it has been acknowledged that experimental approaches tend to work better with relatively straightforward matters (Denscombe, 2014). In this instance the causes of delay are complex with numerous factors contributing to it and therefore any

intervention to reduce delay is unlikely to have a clear causal pathway. As a consequence there is great difficulty in choosing control variables to exclude all confounding variables, another recognised drawback of experimental designs (Bowling, 2014; Blaxter, 2010). Experimental designs possess further

disadvantages; they are costly, time consuming and methodologically

challenging and it is argued that they should only be used where there is doubt as to whether an intervention is effective (Eccles et al., 2003). Furthermore, due to a lack of information on effect size it is not possible to determine accurately the appropriate sample size for a trial. A final significant downfall of

experimental research is that whilst such designs are effective in isolating the impact of an experimental variable and can therefore determine the size of effect it has, it does not allow appreciation of the reasons how or why it affects outcome (de Vaus, 2013). Due to concerns regarding the appropriateness and

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suitability of an experimental design, non-experimental (observational) designs were considered.

Retrospective designs (such as case notes review) as previously stated (2.3.3) are subject to missing and incomplete data (Nagurney et al., 2005) and

therefore were deemed unsuitable to gather the required information. A prospective longitudinal cohort design would reduce the chance of recall bias compared to a cross-sectional design but was not a suitable choice in the present study because:

• Whilst ACL injuries are the most common cause of pathologic motion they still make up a low overall percentage of knee injuries encountered. • Cases may present at many different sites making it unfeasible to ensure

all potential cases are identified at initial presentation.

• Recall bias would not be eliminated as patients would still have to recall the time of initial injury.

• On the basis of previous evidence of delay to diagnosis and specialist consultation the cohort would have to be followed up over many years. The methodology chosen was a cross-sectional survey. This allowed data to be collected simultaneously at a number of sites within a relatively short time period.

Surveys involve the systematic collection of data without active intervention and is regarded as inherently positivistic and quantitative (de Vaus, 2013; Abramson and Abramson, 2011; Robson, 2011; Creswell, 2003). As with any research methodology there are advantages and disadvantages to surveys (table 13).

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Table 13: Advantages and disadvantages of surveys

Advantages Disadvantages

• Can aim at representation and provide generalised results

• Simple and straight forward, easy to administer

• High amounts of data standardisation

• With a good response rate can provide lot of data relatively quickly

• Data are affected by the characteristics of respondents (memory, knowledge etc.)

• Surveys rely on breadth rather than depth for validity (a particular

problem for small scale research)

(Adapted from Robson (2011 box 10.2; p240-241); Blaxter (2010 box 3.15; p79-80))

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The survey methodology possessed a number of benefits when considering the aims of this research. It allowed a large amount of data to be collected and was compatible with the aim of generalisation. As opposed to experimental designs it can also provide information on how independent variables affect dependent variables (e.g. why AKCs affect delay) (de Vaus, 2013). Furthermore, surveys can be used for both descriptive and analytic purposes (Abramson and

Abramson, 2011; Robson, 2011; Greenfield, 2002), an advantage for the outlined research purposes and allowed the first two research questions to be answered with a single study.