Barriers And Facilitators Relating To Thai Clinical Nurses Use Of Qualitative Software Tools: Informing Hospital Policy
P James
Keywords
barriers, facilitators, hospital policy, nurses, thai
Citation
P James. Barriers And Facilitators Relating To Thai Clinical Nurses Use Of Qualitative Software Tools: Informing Hospital Policy. The Internet Journal of Medical Informatics. 2009 Volume 5 Number 2.
Abstract
Background
Within the health services in Thailand there appears to be a growing recognition that qualitative research outcomes has increased in accordance with directives from the Thai government and that qualitative research outcomes are related to increased funding possibilities since 1999 (Mayhew et al., 2008). Clinical nursing professionals in Thai private hospitals account for 14% of the overall nursing population, whilst funding and opportunities for research impact on more than 29% of these (MoPH, 2007). Further, one of the main eight pillars supporting new structural health developments in Thailand – research - has taken on a particularly important role in building health-related capacities for all health staff (Health Policy in Thailand, 2009). A public search for research conducted by Thai clinical nurses research revealed that little is written about their experiences or their engagement in using qualitative software tools in evidence-based solutions to clinically identified problems or issues. However, research targeting evidence-based solutions for health matters has generally increased elsewhere using appropriate methodologies where qualitative methods have become popular (McLafferty and Farley, 2006); which helps composite complex and sensitive issues (Holstein and Gubrium, 2003); and that the need to integrate theory and practice through research has intensified (Conway and McMillan, 2005). Unfortunately, this still means that Thai nursing research appears to be underexposed to possible research developments and testing of evidence-based outcomes (based on DoH - UK, 2000). Thus, the new challenge for Thai nursing staff is to use research methodologies
Issues in Qualitative Research Data Analysis
Qualitative research is designed to provide rich, detailed data of a focused contextualised phenomenon or events impacting on personal experiences and perceptions arising from the encounter. In this respect, targeted populations remain small and reflect individuals who have an intimate knowledge of the situation or event and can communicate appropriately as to their specific responses and conditional understanding. However, the process of qualitative data development and analysis is a
As more and more health researchers report using QSTs, their usage appears to have revolutionized the way methodology and analytical composition is carried out. However, the decision whether or not to use QSTs is based on the individual researcher’s requirements, as well as the researcher’s skills and experience with software and technology (Webb, 1999). Nevertheless, using such packages do not automatically apply/create qualitative analysis with/on the generated data, nor do they, by their very use, increase the robustness or rigour of the qualitative research method employed.
When choosing a QST package the researcher’s style of working with the available data is paramount and the package needs to be flexible enough to allow the researcher to interrogate the generated data and develop the adopted analysis in a natural way. It is the type of qualitative analysis associated with the requirements of the research questions that dictates which package is more suitable to use (Williams, Mason & Renold, 2004). Consequently, the choice of package can dictate the type of analysis to be performed and care therefore needs to be taken in the final choice of the QSTs package. In some circumstances more than one may be used, as the data analysis and subsequent literature engagement may force different approaches that lead to different software package treatments. In essence, for many qualitative health researchers one package could be all that is needed. In other health research circumstances, multi-package engagement would need to be utilised, as the specific and ongoing research orientation demands different data treatments that can only be done through multi-package use. Unfortunately, many researchers claim they have used these types of software packages for the data analysis but fail to show specifically how their structural/theoretical propositions have been arrived at as a direct result of an engagement in the software and any corresponding structural, methodological and epistemologically based analysis. For example …
The above issues consequently raise the following questions:
What are the issues that clinical nurses consider when using QDA in qualitative research?
How do clinical nurses choose appropriate software for use in qualitative research?
What benefits and advantages do clinical nurses see in using appropriate software for use in qualitative research?
These three questions are posited in an attempt to illuminate the issues surrounding clinical nursing roles, experiences and influences.
Methods
To consider more implicitly the three questions raised, this empirical research paper utilised a qualitative approach (Walsh, White, and Young, 2008) to understand the perceptions and experiences of clinical nurse experiences in Thai private hospitals using a focus group methodology largely creating a purposeful element of context and flexibility (Cassell & Symon, 2004). Given the lack of purposeful research in this area, this methodology is seen as appropriate for generating contextual data underpinning the creation of richer theory development (Cayla and Eckhardt, 2007).
Qualitative research using focus groups have been carried out by many researchers (e.g. Monolescu and Schifter, 1999); O’Connor and Madge, 2003; McPherson and Nunes, 2003). Unfortunately ...
Such methods may radically help develop data that would otherwise be lost or be considered unavailable. As such, focus group research is considered a …
The population for this study were private hospital primary care clinical nurses in four (4) private hospitals in Bangkok (after Carman, 1990). The criteria of theoretical purpose and relevance (Glaser & Strauss, 1967) were applied to the targeted population. After general but intensive discussions with each of the four hospital management (where ethical approval was sought and gained), the favoured target frame for each hospital was the general medicine department and therefore twelve (12) clinical nurses (GM) as key informants (three for each hospital) who used or were using qualitative research methods were thus determined as the resultant sample frame (after Harrel and Fors, 1992). The focus group was conducted in English and took approximately one and half hours. The focus group was video and audio-recorded after gaining written explicit permission, and were later transcribed verbatim using the NVivo qualitative software package. To increase the reliability of the data, the actual transcription was returned to each respondent via e-mail for correction, further explanation, addition or deletion and return, which followed the process of validated referral (Reeves and Harper, 1981). Whole-process validity was achieved as the respondents were considered health professionals (Tull & Hawkins, 1990) and knowledgeable of the context and content associated with the research questions presented earlier in this paper.
The focus group was initially manually coded using Copernic desktop according to sub-themes that 'surfaced' from the focus group dialogue using a form of open-coding which is derived from Glaser (1992a) and Straus and Corbin (1998). This treatment was also reinforced, strengthened and extended through the use of thematic analysis conducted using the NVivo qualitative software package (Walsh et al., 2008). In this way, no portion of the interview dialogue was left uncoded and the overall outcome represented the shared respondents views and perspectives. Various themes were sensed from the use of NVivo package, as well as from the manual coding. This triangulistic form of interrogation was an attempt to increase the validity of the choice of both key themes and sub-themes through a triangulation process. NVivo was then further used to explore these sub-themes by helping to pull together each of these sub-themes (Harwood and Garry, 2003). In this way, it was possible to capture each respondent's comments on each supported sub-theme and place them together for further consideration and analysis. Categories and properties are abstractions in the sense that they represent elements and experiences of more than one respondent’s story. This aspect was utilised further by asking respondents, through a second e-mail, to attempt to place the identified sub-themes in terms of whether they felt that either was a barrier or facilitator – thus including the respondents as continuing active agents in the collection and consequent analysis of data.
Presentation of Framework Outcomes
The research questions were mapped to the generated eight (8) major themes, as indicated in Table 1 – Main and Sub-Themes. The sub-themes (21) are further discussed below. The outcomes of this research inquiry in terms of the most discussed sub-themes and the total number of references for the sub-themes are also indicated in Table 1, as is the determination of whether each identified sub-theme addresses a barrier or is an facilitation opportunity. Further, Table 2 indicates the numbers of extractions that help with determining the research outcome.
Results
The style adopted for reporting and illustrating the data is influenced by Gonzalez, (2008) and Daniels et al. (2007) and is formulated below, focusing on the raised research questions and the resultant main themes.
Figure 1
Figure 2
What are the issues that clinical nurse managers consider when using QDA in qualitative research?
Main Theme – Personal
Clinical nurses have conducted qualitative research and find that as one respondent (CN11) indicated …
However, it was indicated that there was little time for research, so many nurses worked at home too. This notion was supported by one respondent (CN2) as …
An issue that was raised by many was the notion of time available for doing research and thus was suggested by one respondent (CN9) as …
Another major issue that was raised reflected specific coding issues when conducting QDA analysis. An example, raised by one respondent (CN11) suggested that …
Main Theme – Research Support
As far as support for doing research, one respondent (CN8) indicated that …
In terms of collaboration, many nurses appear to prefer to do research in groups. As one respondent (CN10) indicated …
Main Theme – Software
Coding issues were raised by some respondents because they were considered difficult and messy and that the learning curve for using the software appeared to be fairly steep for some. On this one respondent (CN3) suggested …
A feature that received wide consideration by the respondents was software training. Most respondents indicated that training was a necessity, as one respondent (CN5) indicated …
How do clinical nurses choose appropriate software for use in qualitative research?
Main Theme – Choice
Aspects that appear to influence the qualitative researcher’s choice of software include whether the project is individually or team based; the theoretical qualitative approach to data analysis; the defined methodology characterised in a way that helps with the application of appropriate use of the software package (Fielding & Lee, 1998). When asked how nurses choose software the answers were characterised as complex, as well in-depth. For example, one respondent (CN8) indicated that …
Cost of software was raised as an appreciable barrier. As one respondent (CN11) indicated …
Main Theme – Personal
As far as personal experience is concerned, many respondents had little or no direct experience in working with contemporary qualitative software. As one respondent (CN9) suggested …
Main Theme – Software Features
A major issue that was brought out, as depicted by one respondent (CN4) was the need for software to be …
There was an overwhelming understanding that software was needed, and as one respondent (CN9) stated …
Another issue that was raised related to support. As one respondent (CN12) indicated …
What benefits and advantages do clinical nurses see in using appropriate software for use in qualitative research?
Main Theme – Benefits
On the issue of enhancing research, one respondent (CN3) suggested that …
An issue that was raised by respondents reflected the ease of preparation of media prior to using QDA. As one respondent (CN5) suggested that …
Another issue that was raised was that of triangulation. As one respondent (CN10) indicated …
Some respondents stated their need for greater speed in the analysis of data. As one respondent (CN5) suggested …
The issue of collaboration was raised by some respondents. As one respondent (CN6) suggested …
Main Theme – Advantages
Another major issue concerned the presentation of research results. Many respondents, typified by one (CN9) indicated that …
Some respondents indicated that software packages were now becoming an important tool to ensuring the quality of their work – especially in terms of the audit trail. As one respondent (CN11) indicated …
Discussion
This discussion will focus on the barriers and facilitators as developed through the theme development process. The outcomes indicate that there are 8 barriers and 13 facilitators (Tables 3 and 4 below) and that these together illustrate the diversity of research practice opinion of Thai clinical nurses. The stars (*) suggest where the emphasis is projected for their consideration in the research process.
Figure 3
Figure 4
The findings above raise important topics that need to be considered by management of nursing facilities on how to initiate and develop appropriate qualitative research outcomes in health settings. The findings suggest that careful management of qualitative research projects are necessary and there is a need to help clinical nurses perform research more effectively by focusing on relieving the barriers and enhancing the facilitators.
Reducing the Barriers
In terms of the first research question. Hospital managers could help to give more time for research (following O’Grady et al.; 2007), through developing on-site mentoring schemes; introduce specialist training in research methodologies through collaborative instruments with universities; streamlining the research process so that Thai clinical nurses could learn and engage with a more effective research process (Majumdar and Boonyanuluck, 2001). Further, introduce research teams that span across clinical disciplines that are designed to offer greater awareness and sharing of research protocols, processes and outcomes (Klunklin et al., 2010).
In terms of the second research question. Hospital managers could help choose software for qualitative analysis in conjunction with clinical nurses requirements and views along with other users; and provide on-going training support (Rubin and Rubin, 1995). Hospital managers could provide more integrative and streamlined research provision that that would also help to mitigate the effects of costs associated with research development and enhance deployment of new evidence and other research outcomes.
In terms of the third research question. Hospital managers could introduce new research designs in order to help reduce data coding issues (Harwood and Garry, 2003), enhance triangulation and provide for research audit trails (St. John & Johnson, 2000). Managers could also introduce collaborative structures across clinical disciplines (Adams and Vigilante, 2010) that would help with making focused decisions on software requirements that are pertinent to overall research needs.
Enhancing the Facilitators
In terms of the first research question. The pressure on nurses to publish (Melland, 1995) may be seen by some clinical nurses as a difficult part of their work schedule as its not part of their primary job (Schilling, 2005) and this may be reduced by potentially introducing team/group publication profiles, so all team members working collaboratively can be seen to have some input into publishing research (Stone et al., 2010). To increase the opportunity for publishing it may be appropriate to introduce pairs of researchers - as mentor and researcher - (Pololi et al., 2004) where experienced researchers could cooperatively publish research with less experienced colleagues. Hospital managers may realise that introducing nursing personnel to a more structured and supported research ethic will lead to greater collaboration, increased speed of research development and publication and influence a wider scope of research interests possibly leading to their own particular nursing specialty (Chester et al., 2007). Hospital managers may need to recognise that clinical nurses have valuable experiences to share (Heinrich et al., 2008) and that publishing research may provide the internal mechanism that helps clinical nurses become more knowledgeable and involved in their clients health and medical requirements.
In terms of the second research question. Hospital managers could introduce specialist training in research methodologies through collaborative mechanisms (such as iPath and Hospital OS) with research providers (Adams and Vigilante, 2010), that would lead to a reduction in preparation requirements whilst easing issues with research method adoption and creating transparency of the audit trail leading to increased confidence in research outcomes.
Managers could recognize the diversity of research requirements and suggest packages that meet a variety of requirements – that although may appear expensive can be used by the entire research group, rather than by singles/pairs operating independently.
Hospital managers could continue to build group/teams of researchers (following Pololi et al., 2004) that could widen the scope of research interest and thereby broaden the level of interests in further collaboration mechanisms. As publishing research becomes a major driver in clinical departments, mechanisms that introduce a pertinent and focused research culture may help to reduce the resistance to engaging in these activities, as well attempting to create additional value in terms of new knowledge and diversified skill application.
In terms of the third research question. This study potentially helps resolve conflicts pertaining to managerial implications of managing a nursing facility by making qualitative projects more effective and focused on the decisions pertaining to health matters thus reducing waste and developing more informed nursing staff – largely attentive to what matters to management, the clinician and health client. By engaging in and managing research projects, clinical nurses will be able to develop their skills in formal clinical investigation along with their writing, communication, and presentations skills and by doing so expand their clinical knowledge competences in their practice arena whilst taking greater responsibility for their nursing practices. Consequently, as such, there appears to be greater recognition in nursing circles of the importance and role of the development and diffusion of health research practices (Tetroe et al., 2008).
Conclusions
The use of qualitative research in a health setting is gaining ground and for some qualitative researchers QSTs offer speed and flexibility in assessing and analysing large volumes of generated data. QSTs are utilised by small numbers of qualitative researchers that attempt to use technology to explore and make sense of qualitative related-data through evidence clinical nursing practices that can enhance a qualitative researcher’s primary investigation, methodological and data analysis response and reporting. The developed research questions were mapped to the generated 8 major themes, and supported by 21 sub-themes. The qualitative outcomes presented, highlight the various experiences, perspectives, opportunities and challenges that Thai clinical nurses face. The outcomes indicate that there are 8 barriers and 13 facilitators and that the impact of this research together suggests that top-level hospital managers need to build a more equitable resource base to streamline the available research provision to give greater support to clinical nurses engaging in evidence-based qualitative research.