RATIONALE FOR THE METHODOLOGY

I must be implicit that the choice of methods for this research have been limited by the methodology used for the broader study. I have therefore detailed below the way in which each of the chosen methods compliment this research.

5.3.1 Cross sectional study

The principal aim of the cross sectional study is to develop a thorough picture of the extent of support worker utilisation and the current workforce models and service context in which support workers are

utilised for the delivery of older peoples' intermediate care and community rehabilitation teams in England. I also anticipate that the results of the cross sectional study will lead to identification of service level factors that are associated with the utilisation of support workers.

The inherent reasons for conducting cross sectional studies are to enable rapid capture of current events in the community and to generate

research hypotheses based on the information captured. There are cross sectional studies that have demonstrated support workers comprise a large percentage of the community rehabilitation and intermediate care workforce (Barton et al., 2005a, Enderby and Wade, 2001, Farndon and Nancarrow, 2003, Nancarrow et al., 2005b). These studies however are not current. Furthermore as I have identified in section 2 (context), community rehabilitation and intermediate care services are particularly sensitive to policy and broader NHS changes and as such are continually evolving. I consider it vital therefore to undertake a cross sectional study to enable an up to date picture to be painted of the support workforce and the current context they are situated in.

In addition, the choice of this methodology reflects that which has been used in other studies of intermediate care and support worker research (Enderby and Wade, 2001, Farndon and Nancarrow, 2003, Nancarrow et al., 2005b). A more up to date cross sectional study therefore enables

114 longitudinal comparisons to be drawn between these earlier studies and the results of this study.

Importantly, the use of a cross sectional study also allows for the

remainder of the study to progress. The capture of details from a broad spectrum of teams by means of a cross sectional study provides the opportunity to select a sample of teams to participate in the prospective study.

5.3.2 Prospective study

The prospective study was chosen as a methodology so that detailed patient, staff and team level data across a range of teams could be obtained and utilised to analyse the contribution and relative impact of support workers to patient, staff and team outcomes.

The prospective study, as detailed earlier in section 5.2, comprises the collection of several different types of data using different data collection techniques from twenty community rehabilitation and intermediate care teams. The prospective study therefore encompasses the collection of patient level information for each patient admitted to these twenty

services over a three month time period; one-off staff satisfaction data for all staff providing these services; staff activity data for each patient

admitted to the service over a three month period; and one-off service data collection.

The choice of the three month data collection period for each patient, and also for staff activity data, was influenced by the results of the Leicester and Birmingham National evaluation of intermediate care. Their study demonstrated the median length of stay of an intermediate care patient is between 18-28 days (Barton et al., 2005a). Three months therefore allows for allows ample time for change in health status to be measured as well as the staff activity data to be collected for each patient‟s length of stay.

115 Collecting staffing activity data for each patient also enables more

accurate analysis of the direct impact staffing activity has on patient outcomes and allows for analysis of patient level predictors for support staff involvement in care. This overcomes the limitations involved in demonstrating associations between staff input and patient outcomes when staffing activity data has been collected separately from patient data as is the case in a great deal of nursing workforce research (Buchan and Dal Poz, 2002, Jenkins-Clarke and Carr-Hill, 2003).

The recruitment of twenty teams for the study enables adequate patient level data to be collected and will give an indication of the team and organisational level factors that may be associated with enhanced patient, staff and team outcomes when support workers are utilised. The

Birmingham and Leicester national evaluation of intermediate care was conducted over a similar time period to what is proposed for this research. Their study generated over 1000 patient records from 10 teams. From these records, sound statistical analysis was able to be conducted of patient change in health status (Barton et al., 2005a). Using this as a guide, it is envisaged that the inclusion of twenty teams will allow for around 2000 patient records to be collected. This amount of data should be sufficient to answer the research questions for this study and to draw reasonably strong conclusions. It must be acknowledged however that this number has not based on a statistically generated power estimate as this type of research and the research questions being asked are exploratory and novel in design.

As demonstrated in other research conducted in this setting (Enderby and Wade, 2000, Nancarrow et al., 2005a, Barton et al., 2005, Godfrey et al., 2005) there is marked diversity among these types of services particularly in skill mix. As such I feel the inclusion of twenty teams in the study will ideally provide enough variation to represent the current CRAICS

workforce, but at the same time be enough teams to roughly group teams with particular workforce configurations together to see if there are any patterns in outcomes with particular workforce configurations. Again the

116 inclusion of twenty teams is not based on any statistical calculations for reasons described above.

5.3.3 Qualitative study

The choice of including qualitative research in the methodology was to gather an in-depth understanding of the dynamics of teams and what role support workers played in these dynamics.

Focus group interviews stimulate discussion and enable the researcher and participants to gain insights and to generate and shape ideas (Hollis, Openshaw & Goble, 2002). Qualitative research, in particular the

Framework approach which has been used in this study, enables greater illumination, understanding and/or qualification of the issues being addressed in corresponding quantitative research (Ritchie and Spencer,1995).

As such the use of focus groups and individual interviews will augment the quantitative data that is generated in the prospective study. I feel it is particularly important to identify and explore potential reasons for results that may arise from the quantitative data and also to contextualise the quantitative results. The focus groups and interviews also enable

identification, examination and qualification of issues that can not be empirically measured by the prospective study activity data or WDQ.

Every team participating in the prospective study will be invited to

participate in a focus group. This will enable the juxtaposing of team level quantitative information with team member experience and perception of events. Individual semi-structured in depth interviews will also be

conducted with a selection of service managers and individual support workers from different teams. Ideally the participation of managers and support workers from teams with varying support worker roles and numbers will be sought. This will allow for more in-depth analysis of the support worker role from both perspectives.

117 A sample of twenty individual interviews was used in the broader study to capture in-depth information from „extended‟ and „novel‟ role practitioners across all teams recruited to the prospective study. It was envisaged that this number would allow for capture adequate representation of extended and novel roles based on previous research of roles in this setting

(Nancarrow, 2003, Nancarrow and Mountain, 2002b). I will utilise interview data from support workers and service managers only in this study and therefore the number of interviews will be dependent on the broader research project.

Interview schedules for the focus groups and individual interviews have been constructed following an in-depth review of the literature, previous research in the setting and through consultation with the broader research team, service managers, staff and service users.