Phase 1 design and methodology

A qualitative approach was adopted for phase 1, specifically phenomenology, in order to accurately establish the lived experience of patients with CVLU. The generic term qualitative research encompasses a range of methods of data collection and analysis characterised by the ‘emic’ perspective or ‘insider’s view’ (Pike, 1954; Salmon, 2012); all aspire to uncover the participant’s understanding of their world and experiences (Bowling & Ebrahim, 2005; Holloway & Wheeler, 2010; Smith et al, 2012). Qualitative research is inductive, providing opportunities to clarify the subjective interpretations which people place on their actions and encompasses a range of innovative

approaches which include ethnography, grounded theory and phenomenology (Atkinson et al, 2001; Meadows, 2003; Astin & Long, 2009). Phenomenological approaches aim to establish the meaning of a given phenomenon and to explore how an individual experiences it, often using first person narrative. Phenomenology endeavours to discover the uniqueness of human behaviour and to unveil and understand the everyday experiences of others without aiming to ‘solve’ the problem posed by the research question (Cresswell, 2007; Pratt, 2012; Salmon, 2012). Phenomenology is valuable, especially within nursing research, as it enlightens our understanding of the life experience and QoL of study participants (Pratt, 2012) and, as such, was seen as the ideal approach for phase 1 of this study which forms a preliminary basis for the subsequent phases.

A variety of research methods can be applied from a phenomenological perspective. Each of the potential methods have a similar focus on the

“…lived experience” (Husserl, 1970; p.240),

of the individual and include participant observation, focus groups, interviews and action research (Lester, 1999). Following consideration of a range of alternative methods, such as a patient focus group or a period of observation of patients with CVLU, interviews were selected as the most appropriate approach in order to effectively capture first person narrative from the study participants (Denscombe, 2007). Interviews are a versatile method, providing the researcher with ample opportunity to understand, explore and clarify the behaviour of participants by allowing their perceptions and views to be explored in their own words (Chung & Munroe, 2003; Kvale, 2004; Bowling & Ebrahim, 2005).

Interviews provide a structured encounter, with that level of ‘structure’ used to categorise them into three distinct types: structured, semi-structured and unstructured interviews (figure 8 below) (Green & Thorogood, 2004; Holloway and Wheeler, 2010). Structured interviews are likened to a

questionnaire that is administered face-to-face and are predominantly applied in quantitative research with pre-set questions and answers that are generally ‘closed’ in nature (Denscombe, 2007). Unstructured interviews are at the opposite extreme; entirely participant led allowing them to speak freely, with minimal intervention from the researcher (DiCicco-Bloom & Crabtree, 2006). Finally, semi-structured interviews fall somewhere between these two extremes, with the researcher able to set the agenda but the participant able to dictate the data produced (Hicks, 2004; Bowling & Ebrahim, 2005). In reality, semi-structured and unstructured interviews sit along a continuum and, within each interview, there is a seamless movement between these two ‘approaches’; such flexibility ensures that the most comprehensive data is sourced (Grbich, 1999; Denscombe, 2007).

Figure 8: Interview continuum.

Since the aim of phase 1 was to gain a candid insight into the daily life of participants, an unstructured approach was felt to be most appropriate, whilst accepting that, on occasion, this approach might move along the interview continuum to a more semi-structured style (Denscombe, 2007). An unstructured approach is a powerful technique for gathering rich data and provides the

researcher (Meadows, 2003; DiCicco-Bloom & Crabtree, 2006). Each interview commenced with the researcher simply introducing the topic and asking the participant to

“….tell me about your leg ulceration?”

thus encouraging the participant to speak in a relaxed manner, free to develop their ideas and thoughts as they wished. In addition, a topic guide of potential questions and themes drawn from the literature review (chapter 3; page 50-92) was developed and available for use, if necessary, during the interviews (appendix 3). The availability of such a guide for such unstructured interviews is not uncommon (Ryan et al, 2009), simply providing a backup to ensure that important themes are not overlooked (Grbich, 1999). During this study, the topic guide was felt to be of particular importance since participants were generally older and the researcher was new to the process. Despite the preparation of the topic guide, it was not actually required during the phase 1 interviews and participants appeared comfortable to speak without prompting.

Interviewing is a skilled process that requires a rapport be built promptly between researcher and participant, thus encouraging the participant to speak openly about their thoughts and feelings within the ‘safety’ of the interview (Green & Thorogood, 2004). Interviewing is a skill, with the role of the researcher of central importance to the quality of the data produced; any lack of rapport and understanding would potentially constrain the quality of the data produced (Grbich, 1999; Meadows, 2003). Indeed, the interview process is founded on the premise that the events and feelings to be explored are of significance to both the researcher and the participant (Grbich, 1999). An important consideration for the phase 1 interviews was how the researcher should introduce themselves and their role to the participant, in order to optimise rapport and mutual understanding. The ‘role’ of the researcher is not without consequence; it assists the interviewer to gain access to the participant, but it also potentially affects the views and actions of both parties during the forthcoming interview

situation (O’Reilly, 2005). Following consideration, it was decided to make participants aware of the researcher’s background as a DN since it was felt that participants may feel at ease when discussing their leg ulcer symptoms, confident in the knowledge that their condition would be fully understood. Such an approach is not without risk, since the perceived status difference between the interviewer and interviewee can give rise to ‘expected’ responses due to ‘social desirability bias’, with respondents responding in a manner that they feel is expected (Paulhus & Reid, 1991).

Despite the DN background, it was essential that each interview be approached from a position of equipoise, thus limiting the impact of the researcher on the data collected (Bowling & Ebrahim, 2005). To achieve this, the researcher was reflexive - actively reflecting on the process as a whole – in order to ensure the veracity and trustworthiness of the data produced (Kvale, 2004; Bowling & Ebrahim, 2005, Clarke, 2006). Such data is bound to the context from which it was drawn; thus it was essential that the researcher became immersed as an equal in order to truly establish, describe, analyse and understand the meanings and behaviour of the participant (Holloway & Wheeler, 2010).

Since the majority of care for patients with CVLU is delivered by DNs in the patient’s own home (Callam et al, 1985; Nelzen et al, 1990; SIGN, 2010) and many such patients are elderly and physically limited (Ebbeskog & Ekman, 2001a), interviews were arranged at a time convenient to the participant at their own home, if the participant was agreeable to this. Interviewing the patient in his or her own environment, it was felt, might encourage them to feel comfortable and hasten the development of rapport between interviewer and interviewee (Green & Thorogood, 2004). If any patient had been uncomfortable being seen at their home and requested an alternate location, a clinic base was available; the location of interview, however, did not prove to be a problem.