TRIANGULATION

As Cohen and Manion (1994) explain triangulation was originally used by maritime navigators, military strategists and surveys to pinpoint a single spot or objective. In the social sciences it is used to map out or explain more fully the richness and complexity of human behaviour by studying it from more than one standpoint. Cohen and Manion (1994) have adapted Denzin’s Typology of triangulation and identified 6 different types. One of these, methodological triangulation, was used in the evaluation of the pilot IPE module to provide a mixture of quantitative tools in the form of questionnaires and a qualitative semi-structured interview method (see chapter 6). This provided different types of data that enabled a richer and more illuminating investigation of the phenomena.

Several important articles were evaluated to identify the most appropriate questionnaires for measuring changes in professional’s attitude and knowledge. These will now be reviewed and the need for the development of new tools explained.

5.3.1 Outcome measures

There are a plethora of tools that have been used to evaluate IPE and many of these have been devised by the individual researcher(s) prior to their study. Few of these have any published measure of validity and reliability. Several authors have used tools to evaluate attitudes and knowledge (Carpenter 1995), (Hewstone et al 1994), (Carpenter and Hewstone 1996), (Shaw 1994) and Parsell et al (1998). Before exploring some of these tools the phenomena of attitude will first be defined in an attempt to understand what it is that IPE evaluations are endeavouring to measure.

5.3.2 Attitude

Attitude is a complex and abstract human phenomenon which is difficult to define although Edelmann (1996) has attempted to do just that. He believes that it consists of three different aspects, a belief or cognitive component, an evaluative component and a behavioural component. In order to understand these divisions it is useful to consider the following example. A professional might know that a Bachelor of Science degree is required to become a radiographer, this is the cognitive component. This might suggest to them that radiographers have to be intelligent and highly trained people in order to do their job, this would be the evaluative component. As a result of this they might take action to try and become a radiographer, this is the behavioural component.

Attitudes held by one profession or group can have a significant effect on their behaviour towards another profession. Therefore it would appear to be a valuable phenomenon to study. Edelmann (1996) suggests that questionnaires are valuable in assessing attitude but that they only assess one aspect, the evaluative component. This supports the principle of triangulation to study complex social phenomena such as attitude so the use of both questionnaire and interviews would help to provide data of changes in attitude. Yet it must be borne in mind that the behavioural component of attitude is all-important. It might still be possible for positive changes in cognitive and evaluative components to occur and be demonstrable yet these might not be expressed behaviourally. Ideally IPE participants behaviour should be observed in practice to determine whether they are applying the changes produced in the other two attitudinal

dimensions. Post-intervention interviews with participants might go some way to providing evidence of self-reported changes in behaviour.

Shaw’s (1994) tools for measuring attitudes comprised a self-constructed attitude questionnaire based upon “situational dilemmas in the workplace” (p51) and a repertory grid technique based on Kelly’s (1955) personal construct theory. During the construction of his attitude questionnaire he interviewed programme participants and then “worked through” the draft questions with the participants until a final format was “agreed”. This would suggest that the questionnaire had content validity (Polit & Hungler 1978 p434). However the reliability he recognises as a problem and presented no figures for this. His repertory grid included the constructs elicited from the learning disability care group. There is some debate in the literature surrounding whether constructs should be elicited from the individuals to whom they are to be applied or that constructs elicited from one group are able to be applied to another group. Fransella and Banister (1977) discuss this issue and conclude that:

“….there is some evidence to suggest that results using provided constructs produce meaningful results….and are

significantly related to individuals’ behaviour” p107

Kelly’s construct theory and the repertory grid technique provide grounding for the identification of contextual issues pertinent to the IPE group being evaluated. These issues are then used to measure change within the group after their interprofessional education experience. This theory and technique will be discussed further later in the chapter as they were thought to be a valuable way to inform and construct valid and reliable outcome measures which could be used to evaluate an IPE group.

Carpenter (1995), Hewstone et al (1994), Carpenter and Hewstone (1996) have reported the results of studies of effects of an interprofessional education programme on final year medical students and fourth year BSc nursing students and medical students and social workers. The evaluations measured changes in attitudes and self-reported knowledge of the participants. The evaluation tools included questionnaires to investigate the factors of ‘breadth of life experience’, ’academic quality ‘ and ‘professional competence’ as well as overall attitude to the other profession (out-group) and to their own profession (in-group). These questionnaires were constructed using pre-programme interviews. Carpenter states that a pilot study was undertaken to obtain

these measures but no details are given and there is no measure of the validity and reliability of the questionnaire used. These measures were selected as the authors believed them to represent factors that could discriminate between the two professions. For example they believed that social workers might score more highly on the breadth of life experience than the nursing group. Again this demonstrates the contextual nature of the tools which might have applicability to nurses and social workers but probably not to the four professions in the present author’s study group. Also the use of just three dimensions is unlikely to be able to demonstrate the broad range of attitudinal dimensions that two professions might have of each other.

Parsell et al (1998) looked at the effects of a two-day pilot multiprofessional education course on 28 undergraduate health care professional students. There were 7 different professions represented, three of which were the same as in the present author’s pilot IPE study group. They used one questionnaire before and 6 weeks after the programme. This contained 10 attitude and knowledge statements related to individual professions. A second questionnaire contained 70 statements about each profession e.g. “dentists must provide out of hours emergency treatment to all patients”, “therapy radiographers are only involved in the treatment of cancer patients”. Again there was no information as to the validity and reliability of the questionnaires or as to how the 70 items were selected.

The lack of published questionnaires and detail as to their validity and reliability precluded the use of any current questionnaires within the evaluation strategy of the pilot IPE module. There also appeared to be a second problem regarding the use of published tools. When analysing the questionnaires they demonstrated a need to use questions which relate to the particular profession taking part in the educational programme/course or to aspects of the programme itself. They are therefore often contextually bound. As was seen in the last chapter there are a wide range and mix of professions who take part in IPE so published questionnaires are unlikely to be able to be used widely in IPE evaluations. This might explain why there are so few published and rigorous evaluations of IPE Barr (1999b). Therefore it was necessary to devise bespoke questionnaires for the pilot IPE module and to determine the validity and reliability prior their use. Shaw’s evaluation of IPE was the inspiration behind the selection of repertory grid technique for the production of a questionnaire for measuring

attitude. This will now be discussed along with the important quality measures of reliability, validity and applicability.