Research Focus

The aim of this study was to explore both health care professionals’ and heart failure patients’ experiences of the decision-making process at the end of life and the impact this may have on the patient having a good death. A constructivist grounded theory method of enquiry was used to identify individuals’ experiences and how the decisions were made with regards to an end of life care pathway. The study and the data gathering process were initially guided by the following aims:

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1) To explore how health care professionals make the decision to place a patient on an End of Life Care Pathway.

2) To explore how decision making at end of life by healthcare professionals could affect patient’s experience.

3) To explore healthcare professionals’ perceptions and understanding of end of life for patients diagnosed with end stage heart failure.

The methodological choices and research design for this study were influenced by the research question. To explore this phenomenon, it was important for me to be able to engage fully with the participants and to understand from their perspective what is was like to make decisions about end of life care. The choice of paradigm was therefore crucial in providing me with the right tools, framework and structure to meet the study aims. A paradigm can be defined as a worldview or a set of propositions that explains how the world is perceived and a paradigm of inquiry informs a researcher as to what is important, what is legitimate, what is reasonable, concerning systematic inquiry (Sarantakos, 1993).

Paradigms in healthcare are often split into two distinct epistemologies that of interpretivist/constructivist and positivist/post-positivist. The interpretivist/constructivist paradigm emerged from the Chicago School in the 1920’s and 1930’s and was made famous in the 1960’s by authors like Glaser and Strauss (1967), Herbert Blumer (1969), Berger and Luckman (1967) and Rubin and Rubin (2005). During this time there was a move from the positivist and deterministic approaches used by classical social scientists and a refocus on the way social science began to construct meanings, negotiate and manage individual groups within various social and historical contexts. Before this movement the methods of research were largely quantitative and firmly based on the positivist paradigm (Saks and Allsop 2007). The

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interpretive paradigm precipitated the development of the tools we now know as qualitative methods. These included methods like grounded theory, phenomenology, symbolic interactionism and more recently poststructuralism and postmodernism. The qualitative methods sought to understand from the participant’s perspective their own experience rather than seek to measure and categorise behaviours and attitudes. The interpretivist researcher focuses on the understanding of research respondents, pursuing the analysis based on the constructivist ontological position that individuals negotiate meaning (Crotty 2011). According to Guba and Lincoln (1994) constructivism adopts relativist ontology (relativism) a transactional epistemology and a hermeneutic dialectical methodology. Crotty (2011) believes constructionism is the view that all knowledge and therefore all meaningful reality as such, is contingent upon human practices, being constructed in and out of interaction between human beings and their world and developed and transmitted within an essentially social context. Quite simply the constructivist view is that the world is not discovered but constructed.

Critics of the interpretivist or constructivist paradigm regularly imply that approaches to human inquiry are rife with threats to validity and that they are of no scientific value (Peck et al 1999). Validity in quantitative approaches relies on rigorous adherence to methodological rules and standards. When these same rules are applied to qualitative research it does not work and that is because interpretive research is often seen as to subjective and lacking in rigor (Mishler 1990, Angen 2000). In an attempt to rectify this position qualitative researchers have either adopted quantitative criteria or disregarded validity as an issue in qualitative research (Silverman 1993). Smith (1984) suggests that it is time we “dispense with the traditional ideas of objectivity and truth and realize that we are beyond method” (pg. 390). Methodological criteria no matter how rigorously applied to qualitative research will not produce the objectivity desired by positivist researchers (Sandelowski 1993). To explore the human experience requires a more fluid,

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contextual and relational understanding and therefore requires an interpretative approach which seeks to understand human thought, speech and action; clearly adopting reductive positivist approaches in this study would not have yielded the type of information or level of understanding required to explore health care professionals decision making when managing the care of patients diagnosed with end stage heart failure.

In comparison the positivist paradigm maintains that reality is fixed and that objective knowledge can be produced through rigorous methodology (Clark 1998). Positivism focusses on establishing scientific facts though the use of scientific method and quantification (Saks and Allsopp 2007). Whilst constructivists may ascribe subjective meaning to objects in their world positivists subscribe no meaning at all instead meaning is discovered through scientific measures and objectivity (Crotty 2011). The historical evolution and nature of positivism was first conceived by French philosopher in the 18th and 19th century Auguste Comte. Comte saw sociology as the very culmination of positivism: a science of man (sic) that would complete the historical evolution of the hierarchy of the scientific disciplines (Giddens 1987). Positivism was cemented in sociology through Comte’s idea of transforming society on the basis of science. Herbert Spencer’s organic theory of society began to build on the work of Comte and there was a move towards a more evolutionary model which saw society viewed as having the same evolutionary principles in its development as biological organisms. The dominance of positivism peaked in the United States with the structural functionalist work of Talcott Parsons and Robert Merton only then to decline in the 20th century with the emergence of poststructuralist and postmodernist paradigms.

Post positivism provided a vehicle for those scientists who did not necessarily agree to the positivist’s way of thinking (Clark 1997). The main influences in promoting post-positivist philosophy were the works of Karl Popper (Popper1959), Jacob Bronowski (Brownowski 1950, 1956), Thomas Kuhn (Kuhn 1970) and Charles Hanson (Hanson 1958). Fundamentally, a

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different conceptualisation of truth was proposed by the post-positivists. Like positivism, metaphysical considerations were still deemed to be an important part of the sphere of science (Bronowski 1956). However, in contrast, a realist perspective of science was advocated with unobservables deemed to have existence and the capability of explaining the functioning of observable phenomena (Schumacher and Gortner 1992). Theoretical explanations therefore had greater predictive value. Like the positivists, science was still deemed to require precision, logical reasoning and attention to evidence but was not confined to that which could be directly perceived. Evidence could be drawn from empirical methods like interviews, self-reports, questionnaires (Bronowski 1956).

Acknowledgement of post positivism has formed the rationale of a number of papers (Clark 1998, Poole and Jones 1996, Schumacher and Gortner 1992) which articulate the need to retain and value all methods and warn against dismissing the empirical approach based solely on the weaknesses of positivism philosophy. Despite the openness of post-positivism to other means of inquiry it can be argued that it still has some of the fundamental weaknesses of positivism and may be inappropriate for some types of nursing enquiry (Angen 2000). The methods used when adopting a post positivism paradigm will still require the researcher to seek causation, predict and explain which is why it often doesn’t lend itself to investigating complex human experience (Guba 1990). Further criticism of positivism is its inability to give insufficient detail to a persons lived experience (Rubin and Rubin 2005; Bryman 2001). However, what is agreed upon by a number of authors (Bowling 2002, Saks et al 2007, Crotty 2011) is that the research method needs to be able to answer the research question. The aim of this study was to explore both healthcare professionals and heart failure patient’s experiences of end of life decision making. To do this I needed to inhabit and be a part of the culture of healthcare professionals managing the care of ‘heart failure’ patients. I needed to be able to interpret how the culture was

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constructed and how behaviours and experiences affected the decision-making process both for the healthcare professional and the patient. The paradigm therefore most suited to this type of inquiry would be interpretivist /constructionist.