The phase two of the research design was on model development aimed at enhancing the provision of PMTCT services as reflected in chapter five. The PMTCT practice model was developed based on the research findings in phase one of the study on experiences of HIV positive women after utilising the PMTCT services as discussed in chapter four. The conceptual framework (systems theory), the literature review also formed the basis for developing this model. Model development also integrated elements of the systems theory: environment, input, process and output so as to formulate a PMTCT practice model. All these were organised following theory development designs and methods described by Chin and Krammer (1991:74) and Walker and Avant (1995:39), making use of concept analysis, synthesis and derivation. The model was further refined and evaluated using a modified Delphi technique (Hasson & Keeney 2011:1696).
3.3.1. Concept Analysis
Walker and Avant (2011:160) define concept analysis as a mechanism for identifying a set of characteristics that are essential to give meaning to a particular concept. The authors further state that this process of concept analysis may be done when concepts are not clear or are outmoded. In this study this process formed the basis for developing a practice model for PMTCT services. Therefore in this study, the term “PMTCT services/care” was described and utilised within the systems context of the study. According to Walker and Avant (2011:160), the first and most important step in conducting concept analysis is concept selection. The concepts that were selected for this study were: PMTCT services delivery, within the context of the systems theory. The systems approach was used to analyse the Zimbabwean PMTCT service delivery. Following an in-depth review of literature, the researcher selected the concept of PMTCT services/care because of its appropriateness to the topic under study that had to do with experiences of PMTCT clients as they interfaced with the health care system. The PMTCT services were viewed from a systems perspective. Different views of a systems approach in health services delivery were identified from different authors. (World Health Organisation 2012a, Ravitz et al 2013:355, Brails ford 2012:1). A system was then defined as a whole, with interrelated parts characterised by elements such as: having PMTCT programme inputs, processes, and output/outcome or impact. These components for the systems theory formed the basis for model development. (see chapter 5, section 5.3 on structure of the model).
3.3.2. Synthesis
According to Walker and Avant (2011:107-118) synthesis refers to the generation of new ideas by examining data of new insights or develop statements about relationship through observations of phenomena. Concept synthesis always begins with raw data. In the context of this study, the research findings from phase one of the study, reviewed literature, systems theory that underpinned the study, all facilitated generation of innovative approaches for developing the PMTCT practice model. The researcher also utilised the systems perspective for identifying key and relevant concepts for the model as well as fitting the results of concept analysis within the selected theoretical framework (systems theory). The relationship of all these elements within the context of the systems approach remains critical in the establishment or formulation of the PMTCT practice model. (See figure 5.5 in chapter 5 reflecting the relationship between different elements of the models).
3.3.3. Derivation
Grove et al (2013:118) indicate that concept derivation is done in situations where the researcher or theorist finds no concept in nursing to explain a phenomenon. These concepts that are identified would provide the insight required. The authors further highlight the fact that in such a scenario it is critical that the selected concept is examined for its fit, meaning and modified so that it is consistent with the nursing context.
According to Walker and Avant (2011:172) the process called theory derivation refers to a scenario of transposing or redefining a concept or theory from one context to another. This approach of theory building may be necessary if the existing theories are considered outdated and new innovative approaches/perspectives are required. According to Walker and Avant (1995) the purpose of theory derivation is to get strategies of explanation or prediction about a particular phenomenon, that is poorly understood and there are no current means to study it .In this study theory derivation was conducted in all phases of the study, in interpreting data on experiences of participants, linking and discussing research findings with literature that was reviewed. In addition to this, the study utilised basic approaches of Walker and Avant (1995) and the systems perspective to develop the PMTCT practice model. Finally, the researcher utilised Chin and Krammer (2011:237)‘s criteria (modified) for evaluation and a modified version of the Delphi technique as cited by Hasson and Keeney (2011:1696) for peer review to refine the model. The evaluation process is thoroughly discussed in chapter 5(section 5.5).
3.3.4. Model Evaluation and refinements
For model evaluation and refinement, the Delphi technique was used. Hasson and Keeney (2011:1696) state that it is a technique used to explore and predict group attitudes on a particular subject. The authors state that the Delphi technique is characterised by anonymity, controlled feedback and aggregation of group responses. According to Wilkes (2015:43), this technique is often used by nurses for a variety of purposes: tool development, nursing standards and curriculum development. Adler and Ziglio (1996) in Wilkes (2015:46) state that the criteria for the selection of the panel of experts are usually knowledge and experience, capacity and willingness to participate and effective communication. In this case a panel of four experts was purposively selected for their expertise in nursing, midwifery, nursing education, PMTCT and model development. The table 3.1 below reflects the panel. The experts were coded 1, 2, 3 and 4.
Table 3.1: Panel of expert reviewers
Expert Country/Address Rationale Comments
1 University of
Sasketchwan,
College of Nursing Science. Canada.
Expert in model
development and research. Vast experience in nursing education in Zimbabwe and in Canada
For the model to be versatile, incorporate the global perspective, for it to be used in other Third World settings
2 University of
Zimbabwe, College of Health Sciences, Harare, Zimbabwe.
Vast experience in nursing education and research. Also an experienced midwife.
Present model in broken down elements.
Put arrows to show interconnectedness of elements 3 National University of Science and Technology, School of Health Sciences, Bulawayo Zimbabwe. A researcher. An
experienced midwife and midwifery tutor. Experienced in PMTCT care and
practice.
Reduce the number of circles to enhance simplicity and clarity.
Model can be incorporated into the midwifery curriculum
4 Mpilo School of Midwifery, Bulawayo, Zimbabwe
A researcher. An
experienced midwife and midwifery tutor. Experienced in PMTCT care and
practice.
Model too busy.
Remove nursing process. Model can be a useful tool for teaching purposes
Three rounds of communication were done before the model was finalised. The mode of iteration was mainly by way of email and Skype. The panel was requested to evaluate the model in terms of clarity, simplicity, generality, accessibility and importance of the model through a questionnaire (see annexure G). Detailed below is the procedure followed plus the responses from expert reviewers:
Expert reviewer 1, an academic with expertise in model development, teaching in Canada but also familiar with third world contexts like Zimbabwe and having taught midwifery and practised as a midwife in Zimbabwe, recommended that the model should be applicable in resource poor settings other than Zimbabwe. So the reviewer felt the global
environment of the model must be incorporated. Subsequently the global perspective was incorporated in the environmental context.
Expert reviewer 2, an academic and experienced researcher felt the model could be made simpler by first breaking it down to its various elements before putting them together. Another comment from the model expert was that the interconnectedness of the model elements should be reflected by the use of arrows to enhance clarity. Subsequently this was attended to.
Expert reviewers 3 and 4, the two midwifery tutors with extensive experience in midwifery and PMTCT practice, generally felt the model was too “busy” and could be made simpler and clearer if the many circles were removed. These were removed. In addition, expert reviewer 4, stated that the description of the processes should be simplified and not involve processes like the nursing process within other processes. The recommendation was implemented. The two midwifery tutors were generally impressed by the fact that the model included aspects of quality assurance and felt that it could be used for teaching purposes in midwifery schools.
The researcher emailed the questionnaire to the experts who in turn emailed back their responses. Following the first round of responses from reviewers, the researcher duly made adjustments as per recommendations. The adjusted model was then emailed back to the expert reviewers. This round was then followed by a Skype interview which yielded nothing divergent. The researcher then emailed the reviewed model back to the expert reviewers. The feedback from the reviewers reflected generally satisfaction with the adjustments made on the model. The general feeling was that overall the elements of the PMTCT practice model and overview were clear and well explained.
3.4. CONCLUSION
The research design and methodology for the study on experiences of HIV positive PMTCT clients as they interfaced with the PMTCT services at a central hospital in Zimbabwe was discussed. A descriptive phenomenological approach was utilised for the study. To ensure scientific rigor, the study employed measures of trustworthiness. The chapter also gave a detailed description of the data collection and analysis process. The chapter also gave a snap shot of the model development process. The succeeding chapter is on data analysis, interpretation, presentation and description of research findings for the study.
CHAPTER 4
PRESENTATION, INTERPPRETATION AND DISCUSSION OF RESEARCH FINDINGS
4.1. INTRODUCTION
Chapter three addressed the research design and methodology. This chapter gives an account of the research findings. The research findings were derived from the analysis of the interview transcripts of women involved in the PMTCT programme and participated in the study at one of the major Central Hospitals in Bulawayo, Zimbabwe. The data collection process followed a qualitative approach and was done mainly through in-depth interviews, with the aim of exploring the experiences of women who have utilised the PMTCT programme as they interfaced with the health care system. Data is presented in the form of Super-ordinate themes, themes and sub-themes that emerged from data analysis. In this chapter the researcher will also give an interpretive report on the meaning of the data in relation to the literature reviewed.