Study platform

Peacock et al. (2009) described the use of a virtual learning environment (VLE) in support of qualitative online research, highlighting the importance of the online environment being user-friendly and conducive to generating meaningful discussion among participants. Based on the recommendation of the University’s Technology Enhanced Learning team, a VLE hosted by Blackboard® called CourseSites was utilised. The advantage of this VLE was that participants were able to choose their own pseudonym and the discussion boards utilised a very similar method of operation to the one the researcher was very familiar with from using Blackboard Learn® in teaching activities. Peacock et al. (2009) set out a number of recommendations of ways to potentially enhance participant engagement with online

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focus groups. These include welcome messages, provision of sufficient instructions of use and creating discussion threads within the VLE which would elicit responses.

Despite Peacock et al. (2009) not couching this advice in evidence of its effectiveness, it stood to reason that this approach constituted good practice, based on Peacock et al.’s (2009) reflections on the experience of facilitating online focus groups for the purpose of research, this advice was therefore followed. The study VLE therefore had its own home-page, within which participants could access the following areas by clicking on tabs: the discussions area, specific help-pages put together for the study, a Blackboard® generic help site, and information about the study, which also contained material on reflection on learning which were considered to be of use for all participants when they have completed the process of the study. Figure 9 shows the participant’s view of the home-page.

Figure 9: The study home page

197 6.2.2.3 Use of case vignettes

Scenarios are useful in creating a narrative with which the participants may identify, in addition to bringing the subject matter to life (Pommeranz et al. 2012). Bloor et al.

(2001), considered vignettes as “focusing exercises”, which are presented to participants in order to develop discussion. Furthermore, Jenkins et al. (2012) described a method of utilising vignettes in qualitative studies where the researcher releases information in stages and poses questions that are based on the information released at each stage. Spalding and Phillips (2007) suggested that the use of vignettes stimulates a deeper reflection on practice, which may eventually lead to an enhancement of one’s practice following the process of participating in such a study.

Hughes and Huby (2002) regarded vignettes as a useful tool, which enables the researcher to explore participants’ understanding and attitudes towards a real-life situation. According to Hughes and Huby (2002), an important advantage of this method is that it reduces the likelihood of participants responding in a “desirable” way (i.e., what they perceived to be the desirable response to a question or trigger) as they will be responding to a hypothetical scenario rather than drawing entirely from their own experiences. A potential pitfall to the use of vignettes to support discussion may be in the language used: Bloor et al. (2001) suggested that in focus group discussions the researcher may choose to have vignettes purposefully unclear or somewhat vague so that they stimulate rich discussion and debate. There is a potential danger that the vignette may be too vague and the details misunderstood, as Hughes and Huby (2002) pointed out, for this type of trigger to be successful, the language may need to be adapted when used with different groups of participants.

This point was considered carefully when constructing the scenarios with the view that if necessary, the language could be adapted to meet the requirements of the

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different professional groups participating in the study. Spalding and Phillips (2007) warned that because vignettes are constructed by their author, they cannot represent an absolute truth and warned of the danger of compromised authenticity when they are not verified by a person with lived experience of the condition described. Another potential limitation of the use of vignettes was highlighted by Hughes and Huby (2002), who stated that by their nature, vignettes are selective and do not accurately mirror the complex realities of clinical practice. Due to this, Hughes and Huby (2002) argued that the analysis of data generated by use of vignettes needs to be more cautious as it cannot be easily generalised. Despite some of these limitations, vignettes have been used successfully in a variety of methodological designs (Bloor et al. 2001, Hughes and Huby 2002, Lee and Tsai 2011, Jackson et al. 2015). Most relevant to this investigation are Fick et al.’s (2013) and McCrow et al.’s (2014) studies. Both used case vignettes of delirium superimposed on dementia to explore delirium knowledge and recognition in nurses. Fick et al. (2013) reported the process of standardising the case vignettes depicting a delirium superimposed on dementia prior to conducting their study. All of these cases were carefully read and adapted to be suitable for use in a stroke environment. For the present study, two vignettes of hypothetical case scenarios were developed based on the Fick et al. (2013) models drawing on the researcher’s clinical experience working as an AHP in a stroke unit to ensure they would be relevant to this setting. Based on Jenkins et al.’s (2012) model of use of vignettes in stages, it was decided to construct the vignettes as a brief scenario which unfolds over a number of weeks, with trigger questions to be asked following each new piece of information released. This model also made sense clinically, in an attempt to emulate what may happen in practice, when patients develop a delirium over the course of a few days. The scenarios were based on real clinical manifestations of patients with a diagnosis of delirium following a stroke: the first depicting a predominantly hypoactive delirium, followed by the second, depicting

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a hyperactive delirium. The baseline information for both case scenarios was the same. The vignettes and the schedule of questions were circulated among the supervisory team, following this, some minor changes in the details of the case presentations were made. Once the cases were approved by the team, they were not piloted formally, but rather sent to a consultant stroke physician and a consultant in liaison psychiatry who also suggested some minor changes in language, mainly around accuracy of the description of symptoms of the hypoactive delirium case. The vignettes were then approved for use, the final version can be seen in appendix 6.1.