Qualitative data generation methods

As above and as in Tables 2.2 and 2.3, the interpretivist paradigm and

phenomenology are more aligned to qualitative methods of data generation. The most common of these are interviews and focus groups and aspects of these are compared in Table 2.7 below.

Table 2.7 Comparison of aspects of interviews and focus groups as data generation tools

Adapted from Bowling 2002 and Creswell 2013

Interviews Focus groups

Participant/s One participant per interview.

Each interview gathers data from one participant

Several participants (often 6-10) per focus group.

Participants may be purposively selected to have similar or disparate backgrounds. approaches. May be structured, semi-structured or unstructured and may be based on critical incident/s.

Development of schedule from the research; should have relevant theoretical underpinning.

Development may be iterative based on analysis of data from previous interviews

Topic guide: key themes to be explored identified in advance but direction of discussion less structured than interview.

Development of topic guide from the research; should have relevant theoretical

underpinning.

Development may be iterative based on analysis of data from previous focus groups

Researcher/s Interviewer Facilitator plus observer/ note taker

Suitability Suitable for all topics Less suitable for confidential/

sensitive topics

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Interviews Focus groups

Data capture Interview digitally recorded and transcribed. Notes not usually made as may disrupt flow of interview

Discussions digitally recorded and transcribed + field notes made by observer

Data analysis. Themes identified from individuals’

experiences/ views etc.

Framework Approach (Ritchie et al.

2014) or grounded theory approach (Glaser 1967) to analysis; may be theoretically informed.

Themes identified from

individuals’ experiences/ views etc. and from interactive discussions between two or more participants. Framework Approach (Ritchie et al. 2014) or grounded theory approach (Glaser 1967) to analysis; may be theoretically informed

2.7.1 Justification for the use of interviews in this programme of research

The focus of this programme of research was participants’ prescribing decision-making behaviour. Notwithstanding the opportunities for generation of rich data through focus group discussions (Bowling 2002) it was anticipated that since participants’ reflections might be very personal they might feel more comfortable sharing these in anonymised one to one interviews rather than with several strangers in a focus group (Bowling 2002). The research was undertaken in the NHS Grampian area and all locations were within three hours of the doctoral student’s home. Face to face interviews were therefore chosen as the primary method of data generation. Interviews will be considered further in Section 2.8.

2.8 Theoretical underpinning of the programme of research

2.8.1 The need for theoretical underpinning

This programme of research will use an interpretivist, phenomenological,

qualitative approach to explore in-depth influences on non-medical prescribers’

prescribing decision-making. Qualitative research has been criticised as lacking rigour (Greenhalgh et al. 2016) with a lack of clarity about the role of theory (Wu and Volker 2009). A strong theoretical underpinning enhances the rigour of qualitative research and the robustness of quantitative research (Stewart and

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Klein 2016) and is particularly important for translation of research findings into practice (Meyer and Ward 2014).

Bradbury-Jones and colleagues (2014) assert that theory may be used in

qualitative research at five different levels, ranging from being apparently absent to being consistently applied throughout, where it drives all stages of the

research. They recommend the latter approach wherever possible to achieve methodological congruence (Morse and Richards 2002), where theory informs and is explicit throughout the research aim, questions, methods, analysis and results.

It is important that the appropriate theoretical perspective is used (Stewart and Klein 2016). The aim of this programme of research was to explore NMPs’

behaviour of prescribing decision-making so as to clarify influences on this. It is already known that doctors’ prescribing decisions are subject to influences other than the patient’s clinical condition and evidence-based guidelines; the limited evidence available suggests that the same is true of NMPs. It was thought possible that one of the outcomes from this study might be recommendations about educational interventions to support and possibly improve NMPs’

prescribing decision-making, should the research suggest this is necessary, for example to promote the uptake of evidence into their practice.

Any intervention targeting behaviour change must be appropriate (Bandura 1998) and must be delivered in the right way; this too will be enhanced by a strong theoretical basis. A summary of 44 systematic reviews of methods of promoting implementation of evidence-based practice in healthcare found that educational outreach i.e. education delivered in person to health professionals in their own settings, was broadly effective (Grimshaw et al. 2001). Such

education should be delivered at an individual level (Scottish Intercollegiate Guidelines Network 2008) thus any theory underpinning research into influences on prescribing decision-making should also focus at this level. A systematic review of educational interventions to improve prescribing competency in medical and non-medical prescribers identified continuing medical education and

individual feedback on prescribing as being helpful (Kamarudin et al. 2013); this too suggests that interventions should be designed and delivered at the

individual level. The Competency Framework for all Prescribers emphasises the importance of all prescribers assessing and maintaining their own competence

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(Royal Pharmaceutical Society 2016); this again emphasises the importance of understanding influences on prescribing decision-making at an individual level.

2.8.2 The Theoretical Domains Framework

Numerous theories of behaviour change at the individual level exist. In 2005 a large group of health researchers, psychologists and health psychologists identified 33 psychological theories with 128 explanatory constructs (parts of theories) which were relevant to the implementation of evidence-based practice.

They classified and simplified these theories and constructs to form an

integrative framework of theories of behaviour change, the Theoretical Domains Framework, initialially 12 domains. The aim was:

“to simplify psychological theory relevant to behaviour change and to make it accessible to those involved in EBP [evidence based practice]

implementation.”

(Michie et al. 2005 p.29).

The framework was later refined and validated by a group of behavioural experts in 2012; domains were adjusted resulting in 14 domains (Cane, O’Connor and Michie 2012) which are given in Table 2.8. The TDF encompasses both the automatic and the reflective elements of behaviour and has been used in several approaches to promoting implementation of evidence-based practice.

In recognition of the complexity of behaviour change interventions and their determinants, Michie and colleagues developed the behaviour change technique taxonomy (BCTTv1) with the aid of 400 researchers and stakeholders across several countries (Michie et al. 2015). They suggest that this taxonomy is used to identify the content of complex behaviour change interventions and to support related research. Michie and colleagues classified ninety three distinct, non-overlapping behaviour change techniques within the taxonomy but recognised that these are likely to be impractical to use individually. They mapped eighty seven of the techniques into the fourteen domains of the TDF (Michie et al.

2015), demonstrating its usefulness as a theoretical underpinning for research into implementation-related behaviour change.

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The TDF has been used in a wide range of studies to examine the determinants of health-related behaviour, including research into implementation of evidence-based guidelines (Francis, O'Connor and Curran 2012) and into prescribing errors by junior hospital doctors (Duncan et al. 2012). Other recent studies using the TDF include behavioural determinants to healthcare professionals reporting medication errors (Alqubaisi et al. 2016); adherence to evidence-based

indicators in primary care (Lawton et al. 2016) and in healthcare implementation projects (Phillips et al. 2015). French and colleagues used the TDF to identify barriers and facilitators to implementation of evidence-based practice and suggested specific behaviour change techniques to address these (French et al.

2012).

2.8.3 Justification of the use of the Theoretical Domains Framework in this programme of research

This programme of research was undertaken using an interpretivist,

phenomenological, qualitative approach in which data was gathered by means of interviews with individual NMPs. Most interventions in healthcare occur at the individual level between a healthcare professional and a patient. Given that the focus of the research was individual participants’ prescribing decision-making behaviour it is appropriate that underpinning should be provided by a theory which encompasses a number of validated domains influential in behaviour and behaviour change at an individual level.

The TDF was used in this programme of research to inform development of data collection tools, create an initial framework for data analysis (Ritchie et al. 2014) and to report and discuss findings in this thesis and via dissemination elsewhere (McIntosh et al. 2017). The domains of the TDF are given in Table 2.8 along with descriptors.

53 Table 2.8 Descriptions of TDF domains

Adapted from Stewart and Klein 2016 and Cane, O’Connor and Michie 2012 TDF domains Descriptors

Knowledge An awareness of the existence of something Skills An ability or proficiency acquired through practice Social/professional

role and identity

A coherent set of behaviours and displayed personal qualities of an individual in a social or work setting

Beliefs about capabilities

Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use Optimism The confidence that things will happen for the best or that

desired goals will be attained Beliefs about

consequences

Acceptance of the truth, reality, or validity about outcomes of a behaviour in a given situation

Reinforcement Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus

Intentions A conscious decision to perform a behaviour or a resolve to act in a certain way

Goals Mental representations of outcomes or end states that an individual wants to achieve

Memory, attention and decision processes

The ability to retain information, focus selectively on aspects of the environment and choose between two or more alternatives

Environmental context and resources

Any circumstance of a person’s situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behaviour

Social influences Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviours

Emotion A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the

individual attempts to deal with a personally significant matter or event

Behavioural regulation

Anything aimed at managing or changing objectively observed or measured actions

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