Reliability and validity in qualitative research

Golafshani emphasises that reliability in qualitative research is assessed through how trustworthy and credible it is.³¹⁰ In this research qualitative data comprised field notes made about discharge from hospital, patient diaries and

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semi-structured interviews with patients. The interview schedule was

constructed based on literature review, guidance from a patient representative and on feedback from three patients with whom an early version of the interview schedule was piloted. Themes identified in the data were reviewed, discussed and modified by the supervision team. As the main researcher was not a clinician, this meant that the patient experiences reported during interviews could be viewed from a lay perspective rather than through a professional lens with a priori professional assumptions about the delivery of care or ideal patient pathways. That notwithstanding, the researcher was aware that personal

perspectives and concerns about the quality and safety of care could influence how the research was designed and conducted.³¹⁵

Maxwell developed five general categories for judging the validity of qualitative research, which are discussed below in the context of the qualitative

components of this research:³¹⁶ Descriptive validity

Descriptive validity refers to how accurately the data record what participants experienced. After each discharge observation the researcher made detailed field notes about what had happened. During semi-structured interviews patients’ accounts of their treatment were audio recorded and transcribed verbatim so the researcher did not need to rely on notes or memory to keep accurate records of what had been described.

Interpretive validity

Interpretive validity is an assessment of how well the researcher reports participants’ meaning in the study. During the observation stage the

interpretation mainly lay in the researcher’s ability to record the meaning of non-verbal cues in relation to how staff discharged patients for example assessing whether participants appeared frustrated or distressed. If phenomena such as this occurred, the researcher made notes explaining what had been seen.

During semi-structured interviews the researcher followed good practice and checked how patients’ different potential meanings were understood during interviews. This minimised the risks of misinterpretation.

126 Theoretical validity

Theoretical validity assesses how well the researcher uses or develops

concepts or theories based on data. During the analysis of observation data a previously defined framework of contributory factors was used in order to

develop evidence about the contributory factors to risk during patient discharge.

During analysis of semi-structured interviews, concepts developed to describe the function of patients’ medicines management networks were reviewed and discussed in detail to ensure their validity.

Generalisability validity

Generalisability in qualitative research often relates to the ability of the data to describe a phenomenon for a particular group. A range of staff were observed in three settings across two sites. Observations were performed on random days and discharges were observed with different types of patients, for example those of different ages, ethnicities, genders and conditions.

Sampling for the second phase of the research was based on a quota to ensure patients with a range of demographic variables were included.

Evaluative validity

Evaluative validity assesses how well the researcher’s conclusions are

grounded in the data. During the observation research, field notes were made in situ by the researcher and used as the basis for the thematic analysis. Analysis and inferences were drawn directly from the field notes and quotations from field notes were used to provide evidence of the conclusions drawn.

Conclusions drawn from the semi-structured interview data were data-driven and quotations from field notes were also used as evidence. Discussion within the supervisory team focussed on how inferences drawn were data-driven.

Triangulation

Due to the sequential embedded nature of the research design it was possible to verify the researcher’s observations and analysis in Chapter 4 with patients’

retrospective accounts of their discharge from hospital made during semi-structured interviews and questionnaire responses reported in Chapters 6–7.

This is a form of methodological triangulation, which is a further means of enhancing the validity of this research.²²¹

127 Overall quality assurance

The following steps were taken to ensure the overall quality of the research:

• Regular research supervision meetings enabled discussion of all stages of the research from discussion about the sites chosen, the patient health condition and the data collection tools to the themes developed and the inferences drawn. The researcher was also able to regularly and

objectively reflect on the data collected with the team.

• The research was informed by the views of a patient representative who advised about the issues faced by patients when leaving hospital with medicines, the quality and suitability of the data collection tools and the suitability of patient information about the research.

• At the beginning of the project, advice was sought from the Mitchell Centre for Social Network Analysis at the University of Manchester about the research design and again later about social network data analysis.

• Conference presentations about the work encouraged peer review of the research and its findings.

3.9 Summary

This chapter has detailed the methodology and methods used in this research.

Many different data collection tools were developed and applied, including an observation schedule, a semi-structured interview schedule and a medicines experience survey. The analysis methods used included descriptive statistics, social network analysis, inductive thematic analysis, a principal components analysis and linear regression.

Chapters 4–7 will describe the results of the research: firstly, Chapter 4 will present the results of the observations made of staff discharging patients on two cardiology wards; and secondly, Chapters 5–7 will present the social network analysis of post-discharge medicines management from the patient’s

perspective.

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Chapter 4 – How are patients discharged with medicines from hospital?

4.1 Introduction

The aim of this study was to explore how medicines are managed at hospital discharge by the hospital care team. This was to understand more about what patients are told about their medicines and how staff develop patients’

capabilities to use their medicines once they return home. It is presented in two parts: a quantitative analysis of the information staff offer to patients when they discharge them; and a structured deductive qualitative analysis of the field notes taken during the observations using the YCFF.³⁰

The study comprised 100 observations of hospital staff and cardiology patient interactions on the day the patient was discharged from two hospital sites.

Observations were of 55 patient hospital discharges conducted by nurses with the patient’s medicines present. During these discussions patients would be told what medicines they were leaving the hospital with. The researcher also

observed 19 pre-discharge checks of medicines where a nurse, a pharmacist or a pharmacy technician would approach the patient and explain that they were organising their discharge medicines and check which medicines were in the patient’s locker. Observations were also made of 23 instances of a ward

pharmacist discussing patients’ medicines with them with the medicines present and three pre-discharge warfarin counselling sessions conducted by ward pharmacists. Observations took place on 36 randomly selected days between November 2013 and May 2014. The total number of observations and the type of observations made at each site is shown in Table 14.

Table 14: Numbers of observations made by type and site

Observation type Site 1 ward Site 1 discharge lounge

Site 2 Ward

Total

Discharge discussion 12 19 24 55

Pre-discharge check 5 0 14 19

Pre-discharge discussion 1 0 22 23

Pre-discharge warfarin counselling 1 0 2 3

Total 19 19 62 100

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At Site 1 a total of 17 nurses and two pharmacists were observed, either on the cardiology ward or in a hospital-wide discharge lounge where patients were sent from the ward to wait for their medicines. At Site 2 a total of two

pharmacists, one pharmacy technician, one pre-registration pharmacist, 10 nurses and one student nurse were observed, and all patients were discharged from the ward. The presence of a discharge lounge fulfilling the function of supplying patients with their to-take-out (TTO) medicines was the main

difference between the two hospital sites. In this chapter the discharge lounge is treated as a separate entity. In the three places discharges were conducted, the following numbers were observed: Site 1 ward (12 patients); Site 1 discharge lounge (18 patients); Site 2 ward (18 patients).

Discharges were exclusively conducted by nurses, whilst pre-discharge medicines discussions were undertaken by nurses and pharmacists. The

slightly different processes noted during data collection are shown in Figures 18 and 19, which map the discharge stages as they were observed at Site 1 and Site 2 respectively.

National policy about how patients are discharged with medicines gives little detail about what patients should be told about their medicines at hospital discharge.^72,91 The focus of these policies is to set out the inter-organisational responsibilities involved in patient transfer. Local policies are similarly vague about how patients are told about their discharge medicines.

At Site 1 policy states that patients should know how, when and what medicines they should take after discharge; at Site 2 staff guidance simply states that the patient should be given information related to their discharge medicines.

This study, therefore aimed to establish what patients are told at discharge about their medicines at these sites. The results are described in the following sections.

130 Figure 18: Site 1 discharge process

Figure 19: Site 2 discharge process Patient identified as lounge and a nurse discusses them with from ward store or

delivered to ward.

Ward pharmacist discusses medicines with the patient with medicines present. from ward store or

delivered to ward.

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4.2 What do nurses tell patients about their discharge medicines when