In this section, the research design used in the thesis is detailed. First, the author states his ontological position, epistemological assumptions and, hence research paradigm. Next, the unit of analysis is addressed, before the methodological approaches for each of the interlinked projects are outlined.
1.7.1 Ontology, Epistemology and Research Paradigm
Ontology is concerned with the philosophy of existence and the assumptions and beliefs that the researcher holds about the nature of being and existence (Blaikie, 2007 p. 13). Having a medical background, the author entered this research project with a shallow realist ontological position. However, through the training provided by the DBA programme at Cranfield, he has learned that valuable information may be missed by purely relying on objective reality. Exploring quality in health care delivery involves looking into the complexities of the patient-physician interaction. This is where realist and idealist ontologies meet; technical medicine meets with patients through the physician acting as an agent. Thus, it is felt that a stratified ontology is best suited for understanding the “moment of truth” in medicine. Blaikie (2007) p. 16, holds that “the aim of science based on depth realist ontology is to explain observable phenomena with reference to underlying structures and mechanisms”. The depth realist ontology is in line with this DBA researcher’s changed position, and is therefore adopted as the basis for this study.
Epistemology is the theory of knowledge and the assumptions and beliefs that people have about the nature of knowledge. By convention, the epistemological assumption associated with neo-realism follows the depth realist ontology (Blaikie, 2007). Proponents of neo-realism hold that establishing regularities within phenomena or between events is only the beginning, thus rejecting the pattern model of explanation associated with empiricism. It is necessary to follow up by locating structures or mechanisms that produce the regularities (Blaikie, 2007), p. 22. Thus, in this DBA study, the depth realist ontological position leads to the adoption of a neo-realism epistemology.
Paradigms are models or frameworks that are derived from a worldview or belief system about the nature of knowledge and existence (Easterby-Smith et al., 2008 pp. 57-58). Paradigms are shared by a scientific community and guide how a community of researchers act with regard to inquiry.
The physician supplies effort into the delivery of health care; however, this effort is non-observable due in part to information asymmetry (Ma and McGuire, 1997, McGuire, 2001). In order to unpack the phenomenon of interest, it is therefore necessary to rely on physicians’ perceptions based on examples of clinical patient-physician interaction. Thus, an interpretive approach is necessary. The research paradigm is therefore that of interpretivism, as described by (Blaikie, 2007) pp. 124-131.
Research design must address the issue of quality assurance in addition to bias (Flick et al., 2004). Miles and Huberman (1994) propose to include qualitative criteria into the schema of quantitative criteria (objectivity, reliability and validity).
This is an issue of trustworthiness in qualitative research, and encompasses credibility, transferability, dependability and confirmability (Robson, 1993 pp. 402-407). Credibility is about demonstrating that the inquiry was carried out in a manner which ensures that the phenomenon of interest is accurately described.
Transferability corresponds to external validity. Dependability is about ensuring
that the processes followed are clear, systematic and well documented.
Confirmability is about ensuring an audit trail.
The challenges of quality have been addressed in the following ways:
Protocols describe methods and procedures in detail
Description of how data was collected, analysed and transformed is presented
Researcher’s assumptions and biases are addressed
Audit trail is ensured by SPSS, NVIVO, Xls files, and transcripts available for inspection
Quotes are used extensively to ensure authenticity 1.7.2 Research Strategy
For the empirical projects, retroduction has been chosen as a research strategy.
Retroduction, in contrast to deduction and induction, does not follow a linear logic, but rather constitutes a cyclic process. According to Blaikie (2007) p. 83, the chosen research strategy of retroduction follows from the depth realist ontology and epistemology of neo-realism.
Pawson and Tilley (1994) and Layder (1993) have argued that both structures (contexts) and mechanisms must be incorporated in order to provide explanations. The aim of this research is to discover underlying mechanisms to explain observed regularities. Thus, the retroductive research strategy suits the purpose of the research and is in alignment with the researcher’s stated ontological position and epistemological assumptions.
Bias is an important consideration in research strategy, as the process of conducting interviews might influence the responses given (Easterby-Smith et al., 2008 p. 147). Bias is defined as any tendency which prevents unprejudiced consideration of a question (Kvale and Brinkmann, 2009). There are potentially a number of biases in this research. The author’s own reference frame may be imposed on the interviewees both when asking the questions and when answers are provided; the author is a physician and holds views about the phenomenon of interest. One strategy to counteract this potential bias is the use of open ended questions (Project Three). The author’s own frame of reference and consequent perspectives will inevitably influence data collection, analysis and process of synthesis (James and Vinnicombe, 2002), so he has attempted to adopt a reflexive approach as one way that he can challenge his frame of reference and thereby increase the chance of recognizing the influence and limitations that these have on the research (Cunliffe, 2003). Reflexivity is a conscious effort to view the subject matter from different angles and to avoid a favoured angle a priori (Alvesson et al., 2008). It is important to note that adopting a reflexive approach does not lead to improved research outcome (Johnson and Duberley, 2003). The author has endeavoured to maintain an awareness of these factors during the data collection, analysis and synthesis, as advised by Kvale and Brinkmann (2009), and Lofland et al. (2006).
1.7.3 Unit of Analysis
According to Easterby-Smith et al. (2008) p. 103, it is important to be clear about the unit of analysis in advance, as this is the basis for collating the data and subsequent analysis. The term “unit of analysis” in this context refers to the distinct unit about which data is gathered. This is distinct from the level of analysis, which refers to a set of relationships. Together, the terms help define the population of this research. In this research, the unit of analysis is the physician-patient interaction and the level of analysis is the physician.
Next the methodological approaches for each of the interlinked constituent projects of this doctoral research are discussed.
1.7.4 Methodological Approaches for Each Project
In this section, the methodological approaches chosen for each of the interlinked projects are summarized. A multi-methodological approach, suited to the particulars of each individual project, is used. The different methodological approaches are listed below:
Project One: Systematic review – see Section 3.2 from page 85
Project Two: Repertory grid technique – see Section 4.3 from page 178 Project Three: Semi-structured interview technique – see Section 5.3 from
page 230
1.7.4.1 Systematic Literature Review
The purpose of Project One is to study the literature in order to gain an understanding of the factors and contexts that influence physician prescription behaviour. Ample literature exists on the topic, so a systematic review of the literature is conducted. Specifically, the review will:
Explore and map the key issues, frameworks and theoretical underpinnings of physician decision behaviour
Investigate factors that influence physician decision behaviour when prescribing
Investigate which factors, under which contexts, may affect prescription behaviour, and in what ways
Following a systematic review process to address the review question provided a rigorous and transparent process to identify gaps in knowledge and to frame the empirical research projects. Systematic literature review originated in medical research and is described as the process to locate and critically appraise scientific evidence in a transparent and replicable manner {Tranfield, 2003 #533}
. For a detailed description of search and assessment criteria, please see Appendix A.1 Protocol, page 317. Applying a proven, systematic methodology to the literature review has resulted in a rigorous and reliable analysis of the extant literature to inform this study.
1.7.4.2 Repertory Grid Technique
The purpose of Project Two is to explore physicians’ conception of quality. The effort physicians undertake in the delivery of health care is not directly observable due to information asymmetry. Much of what physicians do rely on tacit knowledge forged by years of experience. Understanding how physicians construct the environment in which they operate enables a glimpse into the hitherto un-observable. Thus, personal construct theory is adopted as the research strategy for this project. Repertory grid technique, based on Kelly (1955) personal construct theory, is used to elicit the constructs physicians use to characterize quality in health care.
Repertory grid interviews, providing elements to compare and contrast, has been found to be a powerful tool in management research to bring out deep meanings and unobservable phenomena surfacing low awareness verbalization of how a respondent makes sense of a topic without imposing the researcher’s perspective (Goffin, 2002). Furthermore, the technique is useful for limiting jargon and social desirability (Goffin, 2002, Szwejczewski et al., 2005, Lemke et al., 2011). In this study, repertory grid is used to gain a deeper understanding of physicians’
perception of quality of health care delivery. In particular, repertory grid is used to identify the constructs physicians employ in characterizing quality in health care delivery.
The overall advantage of the repertory grid technique is its flexibility, as it can be used for many different purposes (Jankowicz, 2004 p. 27). The Interview guide was validated and modified through the use of pilot interviews. A more detailed description can be found in Chapter Four, starting on page 183.
1.7.4.3 Semi-Structured Interview Technique
The purpose of Project Three is to extend the findings of Project Two and to gain a fuller understanding of quality by exploring physicians’ perception of enablers and barriers of quality in health care delivery. Interviews are an effective means to explore physicians’ experiences when delivering health care services. Kvale and Brinkmann (2009) p. 1, claim that “the qualitative research interview attempts to understand the world from the subjects’ points of view, to unfold the meaning of their experiences, to uncover their lived experiences prior to scientific investigation”. In order to get insights about the physicians’ perceptions of enablers and barriers to quality in health care, semi-structured interview technique has been employed, as it was deemed suitable for the purpose of this project. Semi-structured interviews allow the researcher to both gain insights about the phenomenon of study, and to keep open the opportunity for the participant to add experiences not pre-determined in the interview guide.
The interview guide includes an outline of topics to be covered during the interview (Kvale and Brinkmann, 2009 p. 130). Interview guides were validated and modified through the use of pilot interviews, which are described in detail in Chapter Five, on page 234.
Next, a summary of the main findings and their links to existing research and literature are presented.
1.8 Summary of Findings and Linkages to Existing Research