Philosophical perspective underpinning this doctoral study

Seminal research texts emphasise that clarity and effectiveness of a research study design are crucial for defining the focus of the research topic (Crotty 1998; Creswell 2007; Mason 2010; Streubert and Carpenter 2011). A sound philosophical underpinning provides a formulated framework on which to explore the phenomena, in this case the practice of rounding in nursing. The process challenges the researcher to question their own assumptions about the research topic, what the research is actually about, and indicates how theory guided the development of the research investigation. Creswell (2007)

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proposes the two most fundamental philosophical underpinnings for any researcher is firstly defining their stance towards the nature of reality being investigated, the ontological assumptions of the research. Then in so doing the research’s epistemological position, what represents the evidence or knowledge of the entity/reality being investigated can follow. For this study my philosophical challenges were to identify:

 Ontological - what is the nature of the phenomena or essence of rounding as a ‘reality’

 Epistemological - what would be acceptable evidence/knowledge to show rounding as a ‘reality’

What we believe, what constitutes social reality (ontology) and epistemological underpinnings form the basis of the philosophical building blocks for a research design (Blaikie 2000; Mason 2010). Although, there is often ambiguity with the concepts due to problematic aspects of language, meaning and misrepresentation of terms (Lowenberg 1993). Crotty (1998) is of the view that ontology and epistemology are often combined together when informing the theoretical perspective of the research. To minimise confusion and ambiguity Crotty (1998) proposes four elements need to be articulated, understood and utilised within the design framework of any research study, the epistemology underpinnings, theoretical perspective, methodology and methods utilised within the investigation.

Creswell (2007) identified research viewpoints (philosophies and assumptions about the nature of reality, known by the term paradigm) on which research architecture is based. Two polemic paradigms, have been identified from reviewing the research designs applied to current rounding research. The objective paradigm views rounding as an ordered measurable reality (Meade et al. 2006; Studer Group 2007) and as the opposite the subjective paradigm views rounding as an interaction from which meaning emerges, often different for each person involved with the interaction (Rondinelli et al. 2012; Harrington et al. 2013). An alternative perspective, a middle ground, is that of constructionism, a paradigm which brings together objectivism and subjectivism, acknowledging for rounding that some concepts can be measurable but also believing ‘meanings are constructed by

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human beings as they engage with the world they are interpreting’ (Crotty 1998 p43). An objectivist or positivist ontology necessitates an ordered observable reality, promoting the use of a deductive and quantitative approach to research design that looks for cause and effect (Schneider et al. 2007). For example, this approach to this research would seek to find the cause and facts related to rounding, patient safety and patient satisfaction but is less concerned with staff and patient experience, preference and opinions of the process. Within the literature there was an overwhelming dominance of the positivist science however within these studies narrative, little attention was devoted to the epistemological context of the research approach. This could be because the majority of the studies replicated the approach set by Meade et al. (2006) to scientifically measure the cause and effect, the facts of the rounding process (Culley 2008; Murphy 2008; Sobaski et al. 2008; Weisgram and Raymond 2008; Ford 2010, Saleh et al. 2011; Krepper et al. 2013, Olrich et al. 2012; Brosey and March 2015; Goldsack et al. 2015).

In these quantitative studies attention was paid to the methods of measurement used to gather and analyse their data and the choice of methodology was not debated, with an underlying assumption that only an objectivist approach would provide the measurement the studies required. The objectivist ontology has the appeal of proving fact, logical inference plus replication from the results from the quantitative studies (of Meade et al. 2006; Studer Group 2007) leading to the development of a rounding evidence base which has only latterly been questioned (Snelling 2013; Forde-Johnson 2014; Mitchell et al. 2014; Walker et al. 2015; Toole et al. 2106). From my own review what appeared to be missing from this approach to investigating rounding was the absolute ability to measure of defined outcomes (falls, pressure ulcers and patient satisfaction) through the inability to isolate these outcomes from other ward variables, for example as highlighted by Hutchings (2012) training programmes and patient assessment processes could impact on reducing falls rates as equally as rounding practice but in a complex ward setting it would be difficult to completely isolate the interventions in order to assign objective measurement. Objective knowing is that scientific measurement creates knowledge, if objective measurement cannot be assigned to a phenomenon, the importance and the actual existence of the phenomenon (subject of the research, in this case rounding) could be questioned (Crotty

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1998). If rounding is only viewed through the lens of measurable outcomes then it’s value to nursing practice and patient care could be lost, as it cannot be objectively measured.

Initially as a professional leader of nursing practice there was an attractiveness to using an investigation process which could prove whether rounding is an effective nursing intervention in terms of patient safety, patient and staff experience. Furthermore, the measures used to compare and contrast the process of rounding were already monitored within my practice setting (falls rates, pressure ulcer prevalence and patient satisfaction). Indeed, such an investigation would have complied with the current prevalent research approach that appeared to provide a prodigious body of evidence declaring the effectiveness of rounding as a nursing intervention (Meade et al. 2006; Studer Group 2007; Culley 2008; Murphy 2008; Sobaski et al. 2008; Weisgram and Raymond 2008; Ford 2010, Saleh et al. 2011; Krepper et al. 2013, Olrich et al. 2012; Brosey and March 2015; Goldsack et al. 2015).

However, in my experience objectivity is almost impossible when examining interactions between patients and staff in the complex setting of a ward environment. Even what may appear to be a simple outcome for example measuring falls reduction is a multifaceted process which cannot be isolated to the one intervention of rounding. From my greater understanding and examination of research philosophy, for rounding as a new process to NHS nursing practice, the relationship between the nurse and patient when rounding occurs first needed to be explored and understood. This exploration and understanding would inform how rounding affects patient safety (falls and pressure ulcers) patient experience as a first step in developing NHS nursing evidence about rounding practice as well as enlightening the nurse/patient care and compassion relationship as rounding has an important role within the 6C’s agenda (DH 2012c). For this reason, it was necessary to explore different approaches.

At the opposing end of the spectrum the subjective approach aims to understand, describe and or translate what is happening from the researcher’s own frame of reference. The ontological preposition focuses on the individuals meaning of the world rather than explanation or prediction events through measurement of cause and effect (objectivism).

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Rondinelli et al. (2012), Harrington et al. (2013) and Walker et al. (2015) used the subjective paradigm to explore rounding, their studies sought the meaning of rounding practice through interpretation and reflection of the individual. As a nurse I believe subjective lines of inquiry add deeper insight into situations that would aid the understanding of the rounding. Similarly, there is a strong belief and argument conveyed in the research literature that patient experiences cannot be objective (Crotty 1998; Creswell 2007; Schneider et al. 2007; Streubert and Carpenter 2011; Parahoo 2014). There are potentially too many intervening variables when the focus of the research is the human social context. The subjectivist or naturalist epistemology is based on the lived experience of the individual through the perception of reality (Schneider et al. 2007). Indeed, nursing knowledge is often gained through understanding and viewing the nature of humans and their condition (Kim 1992). I would propose that in the context of rounding nursing knowledge is gained by describing the everydayness of what is happening between the patient and the nurse in the practice of rounding, which a more subjective rather than objective approach would help to uncover.

In comparison, constructionism is a paradigm in which knowledge is constructed by the understanding of perspectives between people and within societies, exploring social and cultural mechanisms, examining and comparing similarities and differences to generate a greater collective meaning not individual meaning (subjectivism) (Crotty 1998). Constructionism can be seen as a social process whereby reality emerges from ongoing conversation and interactions, and is influenced by the connected relationship of the researcher and the participants (Guba and Lincoln 2004). The purpose is not to evaluate the investigation in terms of true or false but attempt to uncover informed and complex perspectives, for example gaining a deeper understanding what rounding means for both staff and patients. This I would argue provides the most appropriate philosophical perspective to underpin my study. Deitrick et al. (2012) provided an example of a constructionist approach, although not described as such, where the research process listened to what people said, gained an understanding of perceptions and observed what staff were doing, and compared it with documentary evidence to construct the process of rounding for their investigation. Constructionism acknowledges that the governing behaviour (for example how nurses deliver rounding and whether patients find it useful) can

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influence the way meaning is constructed and cannot be viewed in isolation (Silverman 2013; Creswell 2007; Streubert and Carpenter 2011). Within this perspective the world view is neither wholly objective or subjective, but researchers generally use qualitative not quantitative research methods to investigate the phenomena (Crotty 1998).

Although many studies have demonstrated that the process and outcomes of rounding can be measured through the objectivist lens using quantitative methods (Meade et al. 2006; Studer Group 2007; Culley 2008; Sobaski et al. 2008; Gardner et al. 2009; Tea et al. 2009; Woodward 2009; Ford 2010; Berg et al. 2011; Saleh et al. 2011; Olrich et al. 2012; Sherrod et al. 2012; Brosey and March 2015). Only a small number of studies have considered rounding from the subjectivist or constructionist ontological and epistemological perspectives (Blakley et al. 2011; Deitrick et al. 2012; Neville et al. 2012; Rondinelli et al. 2012; Walker et al. 2015) and attempted to generate an evidence base of what is rounding and what does it mean to patients and staff. I believe the process of rounding cannot be independent/isolated from the human (patient/staff) experience.

Fundamental to the methodology is the identification of a problem (Streubert and Carpenter 2011), but I would propose that given the limited evidence base, the research question about rounding practice is still exploratory, both what it is and what it means to the individual and the collective (patients and nurses). Research is needed that adequately describes rounding practice and constructs meaning to NHS nursing practice before we can fully examine or identifying a problem with rounding process and implementing change plans.