Paradigm and rationale

Research is guided by a paradigm (Khun, 1970). A paradigm is a basic belief system or worldview, a framework that encompasses philosophical thought about the nature of reality (ontology) and the relationship between the researcher and what is known and how we come to know, whether the researcher is part of the knowledge or separate from it (epistemology) (Crotty, 1998; Guba and Lincoln, 1994). Subsequently the methodology, influenced by ontology and epistemology, refers to how we gain knowledge

about the world in a practical way (Guba, 1990; Guba and Lincoln, 1994; Crotty, 1998; Denzin and Lincoln, 2000; Denzin and Lincoln, 2005). The paradigm, research question and how data is gathered are therefore intrinsically linked within a specific perspective. The following sections situate the current study, its methodology and methods within the naturalistic, constructivist paradigm. Three alternative perspectives (positivism, post positivism and the naturalistic paradigms) are considered here (Guba and Lincoln, 1994).

3.2.1 Positivism

Positivist researchers assume that one single, measurable, objective reality exists ready to be discovered, within a value-free framework, which can be observed, captured and understood through scientific enquiry (Parahoo, 2006). Distanced from, and independent of, the subject matter, the researcher collects quantitative data to empirically test predetermined hypotheses, discover cause and effect relationships between controllable variables and make predictions that are verifiable and generalisable from the direct measurement of large numbers of randomly selected cases in a rigorous experimental approach with statistical data analysis (Lincoln and Guba, 1985; Denzin and Lincoln, 2000). Some studies, such as drug trials for example, are clearly well served by research carried out from this

perspective. The medication dose can be systematically measured, a large sample of the population can be randomised and controlled and outcomes can be clearly monitored from which statistically significant, generalisable conclusions can be drawn. An inquiry that plans to explore the more

complex and multi-faceted phenomenon of multi-professional care of the deteriorating patient in context however does not lend itself to such a reductionist approach, where variables arguably cannot be controlled or removed, as indicated in Chapter Two, and blinding of the researcher is not possible or desirable.

Thus, as outsiders, separate from the investigation, positivist researchers look for a single truth, causative explanations, prediction and control, using objectivity, deductive reasoning and statistical analysis (Parahoo, 2006), but this is not useful for investigating the complexities of human experiences in context. The phenomenon of interest here requires a different approach to facilitate a deeper understanding of the problem in its natural, contextual setting. Arguably, this could not be best achieved using a positivist

approach.

3.2.2 Post-positivism

Post-positivism emerged from a critique of positivism and this movement is an example of what Khun (1970) described as a paradigm shift. Post-

positivist researchers hold similar beliefs to the positivists in that an external reality is purported to exist and can be measured, but for them there are multiple realities that can only be partially captured (Appleton and King, 2002). Based on a belief that everyone experiences reality in a similar way, there is no clear, definitive objective truth, rather truth discovered is probable. Thus the researcher aims for a detached, objective position while recognising the possible effects of background knowledge and contextual

factors on what is seen and heard in the field. For a study of the

phenomenon of interest guided by this perspective, the researcher might take a mixed methods approach, triangulating qualitative and quantitative data so that errors or faults in each could be overcome. Some researchers recognise however that not all phenomena, as in this study, are conducive to measurement, and meaning can be lost when it is fragmented into

component parts (Allcock, 1997; Annells, 1997). The positivist and post- positivist paradigms, summarised in Table 8 below, with an objectivist measurement and realist stance, arguably have potential limitations for investigating human behaviour and complex social phenomena and are therefore not suited to a study that aims to explore participants’ thoughts, feelings, behaviours, actions and interactionsin the clinical healthcare setting.

Table 8. Summary of philosophical assumptions in three paradigms

Paradigm Positivist Post-positivism Naturalistic

Ontology Single reality

exists Reality exists but may be multiple and impossible to

accurately perceive

Multiple realities exist

Epistemology Objectivist where the researcher is far-removed from the investigation Detached and objective researcher but recognises potential contextual influences Researcher interacts with participants in their natural setting Methodology Experimental under controlled conditions Modified experiments, multiple methods, triangulating qualitative and quantitative data Qualitative data from interviews, observations

3.2.3 Naturalistic or constructivist paradigm

Naturalistic research, developed during the late 19th _{and early 20}th _centuries

by social scientists, encompasses a set of beliefs in which proponents consider experience to be context-bound and socially constructed, that objectivity and neutrality of the researcher is impossible to achieve so their values have to be an integral part of the study, rather than divorced and separate from it (Appleton and King, 1997). Research influenced by this paradigm usually involves collecting rich, thick descriptive data (Geertz, 1973) which is described, analysed and interpreted through a close

relationship between researcher and participants, and where data gathering and analysis are carried out simultaneously. The 1960s heralded a period of development of a systematic approach to qualitative naturalistic inquiry as the positivist approach came under criticism (Rutty, 1998).

Neither the positivist nor the post-positivist approach was adopted for this study, as they were considered unsuitable for the phenomenon of interest. In research underpinned by these paradigms the researcher remains separate from the investigation. As an employee at the research site, with a role in care of the acutely ill patient, the researcher was linked to the

population under investigation and shared some of the values and beliefs of the participants. The researcher could have become detached from the participants, but this was not desirable where the aim was to understand what was happening at ward level between the multi-professional team, and the researcher needed to be close to the action. If one considers that

cultural, social and political factors, this meant exploring how they constructed their own reality in the context of the clinical arena, in the natural setting, anticipating that there might be multiple competing realities. Subsequently this led to the consideration of the constructivist interpretivist approach.

3.2.4 Constructivism

When constructivism underpins an inquiry, phenomena can be studied in their natural setting in order to understand how the participants construct reality in context, where meanings are embedded in the actions they perform (Parahoo, 2006). Constructivists take a relativist stance, that is, participants may behave and think differently in different contexts, relative to the situation and their actions are open to interpretation by any given observer (Appleton and King, 1997). The aim is to develop an

understanding of the meanings they place on the phenomenon, from their perspective. Thus, constructivists argue that reality is relative to the individual and multiple mental constructions of reality can exist

concurrently in the minds of different participants. Each participant sees the situation from a unique position. By talking with the participants and

observing them in practice, the researcher can get close to the action and learn about what happens, some of the hidden assumptions, what these mean to the participants and how they make sense of their world (Charmaz, 2006).

This approach was considered an appropriate strategy for the current research because it matches the aims of the study and reflects a perspective where multiple realities can exist. With a subjectivist epistemology,

participants and researcher can work together to co-create understanding of the phenomenon (Denzin and Lincoln, 2000). The complexity of

healthcare professionals’ interactions, while caring for acutely ill patients, lends itself to exploration directly in the ward setting because it is neither possible nor desirable to remove or separate participants from their

physical environment and study them in a ‘laboratory-like’ situation. While it may not be feasible to access participants’ attitudes and beliefs as static and measurable entities, their interactions and how they bring issues and problems to the fore by their actions in practice or talking about them can be studied (Carter and Little, 2007).

By talking to participants and interacting with them in their daily activities, the researcher gains access and insight into practice, learning from them in close proximity to maximize knowledge generation by engaging in their world. This approach aims to reveal multiple subjective realities, rather than one hard truth, and findings that are relative to the context of the study and relevant to the participants, possibly transferable to other areas rather than generalisable to all (Guba and Lincoln, 1994). Thus, consumers of this research may feel a resonance or recognise similarities with their own practice and subsequently apply them to their own area of work. It is acknowledged however that findings will reflect a standpoint; different researchers exploring the same phenomenon might construct different

knowledge in a different time and place because truth is relative and dynamic.

3.2.5 Summary

In summary, the aim of this study was to provide new and deeper insights into a complex and sometimes problematic area of patient care, so the design was informed by a naturalistic constructivist approach. The goal was for the researcher to be an integral part of the study, to enter the

participants’ social world and its construction simply by being there amongst the action, and through gaining a shared understanding with the participants. A belief that researcher and participants both influence the environment and are in turn influenced by it, meant that interaction and collaboration between the two in this study resulted in joint creation of data and knowledge (Guba and Lincoln, 1989). The next section will explain why grounded theory was the methodology of choice.

3.3 Grounded Theory Methodology

Grounded theory is a research approach, presented originally by Glaser and Strauss (1967) that provides a systematic approach to data collection and analysis as a counter to the positivist criticism of naturalistic research approaches,

…the discovery of theory from data systematically obtained from social research (Glaser and Strauss, 1967:2).

A problem focused approach, grounded theory centres on action, incidents and the main concerns of the participants, providing the opportunity to

study how people experience, approach and resolve everyday tribulations to identify what is happening in practice (Gibson and Hartman, 2014). More simply, it provides an opportunity to study social action and what happens in context (Stern and Porr, 2011). Coupled with the promise of a theory or a framework that will fit, will be relevant and work in practice (Glaser and Strauss, 1967:3), the opportunity to produce something concrete and

substantial made it an attractive option for investigating the phenomenon of interest.

A grounded theory or conceptual framework, developed inductively from the data has the potential to advance understanding of a phenomenon (Higginbottom, 2004). While several authors have noted a plethora of studies using this approach in nursing research (Tarozzi, 2011; Stern and Porr, 2011; Birks and Mills, 2011), it has been used rarely to investigate care of the acutely ill adult. Andrews and Waterman’s (2005) ‘packaging’ study was a singular example identified from the literature review (discussed in Chapter Two) before the current study began. As such it became a

favourable option to fill the gaps in current understanding.

Grounded theory is purported to facilitate the exploration of interpersonal activities and is particularly valuable when little or no previous knowledge or theory exists (McCann and Clark, 2003), therefore it was considered ideal to explore multi-professional ward-based care of the deteriorating patient. It focuses on social action; social processes and the way individuals interact and express themselves socially, providing potential access to their motives

and beliefs from a study of human behaviour. Researchers usually ask open questions about what is happening in practice and watch how people interact in the clinical environment (Sbaraini, Carter, Evans and Blinkhorn, 2011), and as such, GTM is well-placed to explore the complexities of how groups of professionals work together when caring for the deteriorating patient.

The methodology for the current study has been heavily influenced by the work of Charmaz (2006) and the importance of including all key tenets of grounded theory was crucial to its rigour. Her practical guide through each stage of the research process including theoretical sampling, data gathering with interviews and observation, data analysis with coding, the constant comparative technique and writing memos directed the research proposal and the ongoing research process for this thesis (Charmaz, 2006; 2014). Key tenets of grounded theory methodology are explained in more detail in section 3.7 below.

An overview of grounded theory methodology has been presented in this section, deemed as appropriate for the current study because it examines social processes around the phenomenon of interest, the end result of which will be something tangible, a conceptual framework that could explain current practice and guide future improvements. Key elements of the research process will be discussed in more detail in the following sections. How these are operationalised is dependent upon the philosophical

explained below by way of the historical development of Grounded Theory over the last 50 years in the next section.