Tag: qualitative research

Ordinary risks and accepted fictions

Ordinary risksThis new paper you need to read. You also can, because it is published in gold open access form and is therefore free to download to anyone with an internet connection. Lead authored by Michael Coffey, and arising from the larger COCAPP study (see also here, here and here), it draws on qualitative data to examine in detail what staff, service users and carers say about risk assessment and management. Here’s the abstract:

Background

Communication and information sharing are considered crucial to recovery-focused mental health services. Effective mental health care planning and coordination includes assessment and management of risk and safety.

Objective

Using data from our cross-national mixed-method study of care planning and coordination, we examined what patients, family members and workers say about risk assessment and management and explored the contents of care plans.

Design

Thematic analysis of qualitative research interviews (n = 117) with patients, family members and workers, across four English and two Welsh National Health Service sites. Care plans were reviewed (n = 33) using a structured template.

Findings

Participants have contrasting priorities in relation to risk. Patients see benefit in discussions about risk, but cast the process as a worker priority that may lead to loss of liberty. Relationships with workers are key to family members and patients; however, worker claims of involving people in the care planning process do not extend to risk assessment and management procedures for fear of causing upset. Workers locate risk as coming from the person rather than social or environmental factors, are risk averse and appear to prioritize the procedural aspects of assessment.

Conclusions

Despite limitations, risk assessment is treated as legitimate work by professionals. Risk assessment practice operates as a type of fiction in which poor predictive ability and fear of consequences are accepted in the interests of normative certainty by all parties. As a consequence, risk adverse options are encouraged by workers and patients steered away from opportunities for ordinary risks thereby hindering the mobilization of their strengths and abilities.

Reported here is one of the most important sets of findings arising from the COCAPP study. Diana Rose has written a post on the article, which is scheduled to appear on the inestimable Mental Elf site next week. I’m very much looking forward to reading that.

Resilience of community mental health nurses in Palestine

Earlier this week a new article lead authored by Mohammad Marie, and co-authored by Aled Jones and me, was published in the International Journal of Mental Health Nursing. The title of the article is Resilience of nurses who work in community mental
health workplaces in Palestine
, and is the second paper arising from Mohammad’s completed PhD. As the article appears in gold open access form copies can be directly downloaded from the journal’s website for free: or indeed, by clicking either the hyperlinked title or image above.

The larger part of Mohammad’s qualitative dataset is interviews conducted with CMHNs working in the West Bank. Fifteen practitioners took part, from a total population of 17. For the record, that’s 17 community mental health nurses for a population of some three million people. That’s an astonishingly low number by UK standards; for more on mental health needs and services in Palestine, the place to go is Mohammad’s first paper (Mental health needs and services in the West Bank, Palestine) about which I previously blogged here.

Here is the abstract from this latest paper:

People in Palestine live and work in a significantly challenging environment. As a result of these challenges they have developed resilient responses which are embedded in their cultural context. ‘Sumud’, in particular, is a socio-political concept which refers to ways of surviving in the context of occupation, chronic adversity, lack of resources and limited infrastructure. Nurses’ work in Palestine is an under-researched subject and very little is known about how nurses adjust to such challenging environments. To address this gap in the literature this study aimed to explore the resilience of community mental health nurses (CMHNs) who work in Palestine. An interpretive qualitative design was chosen. Fifteen face-to-face interviews were completed with participants. Thirty-two hours of observations of the day-to-day working environment and workplace routines were conducted in two communities’ mental health centres. Written documents relating to practical job-related policies were also collected from various workplaces. Thematic analysis was used across all data sources resulting in four main themes, which describe the sources of resilience among CMHNs. These sources are ‘Sumud and Islamic cultures’, ‘Supportive relationships’, ‘Making use of the available resources’, and ‘Personal capacity’. The study concludes with a better understanding of resilience in nursing, which draws on wider cultural contexts and social ecological responses. The outcomes from this study will be used to develop the resilience of CMHNs in Palestine.

The idea of ‘Samud’ which is referred to above is an important one in Mohammad’s work, and (as I have learned) for Palestinian people. Drawing on the work of Toine Van Teeffelen, here is what Mohammad says about it in his thesis:

[Samud] is the art of living to survive and thrive on their homeland in spite of hardship and under occupation practices. These skills of how to live are used in different aspects of life such as economic, political and social. They can also be used at many levels: individual, family and within the Palestinian community. Moreover, Sumud has been divided into two types: tangible resources such as the infrastructure supporting basic needs (for example, schools and hospitals) which enable the existence of the Palestinians on their land and help them to be more resilient. In addition intangible sources of Sumud also exist, which include: belief systems, religion and social and family support which help the Palestinians to cope with their chronic daily collective suffering.

For Mohammad, Samud is closely related to the more familiar (to me, at any rate) idea of resilience. Or, more properly put, Samud connects to social ecological variants of resilience which place as much emphasis on the social and cultural as they do on the individual.

I’ll stop here and leave people to download and read this new paper for themselves. For those interested, Mohammad, Aled and I are working on further publications from this doctorate: so more will follow in due course.

Studying young people’s experiences of cancer

Jane's PhD

Clicking the image of the front page of Jane Davies‘ PhD in this post will download the complete text of this newly completed doctorate. Danny Kelly and I were Jane’s supervisors, and for a flavour of her study and its findings here is its abstract:

This thesis is the result of an in-depth study, which explored the experience of choice and control in decision making when five young people developed and were subsequently treated for cancer. The study was underpinned by the sociological theories of agency and structure against the backdrop of the developmental nature of adolescence and emerging adulthood. The experience of the disease was situated at a time when these young people were in the process of developing their early adult life plans and were at a fundamental crossroad in the life cycle. The diagnosis and subsequent treatment for cancer at this juncture impacted significantly on the lives of these five young people and those close to them.

Exploratory case studies were utilised in an attempt to examine more specifically each young person’s choice, intentionality, control and freedom in deciding all aspects of decision making, beginning with the onset of symptoms followed by diagnosis and treatment. Interviews, observations and documentary analysis were instigated to generate data. Multiple sources were selected to generate further insights and these included family, partners, friends and health care professionals who were close to the young people during their experience.

Three overarching themes were identified during analysis of the data: ‘life then’, ‘life interrupted’ and ‘life reclaimed’. Key elements of these themes included a number of complex and interrelating factors which were interwoven within the everyday lives of the young people. In the ‘life then’ phase, ‘holding on’ to agency prior to diagnosis and the importance of close and intimate relationships was illuminated. In ‘life interrupted’, agentic power during treatment, in terms of the range of decision making and the complexity of the parental role, were prominent. In ‘life reclaimed’ the ‘different but determined’ nature of young people’s behaviour and re-aligned agency was transparent as they made their way towards the end of treatment.

The findings culminated in the illumination of individual trajectories relating to the fluctuating nature of agency during the cancer experience. These incorporated the three overarching themes as three sequential phases. Commonalities in this regard were also identified across the five cases. Several discussions with practice colleagues resulted in the formulation of potential ways in which ultimately these trajectories might be applied to practice in the future.

For those who may need additional persuading: further to my post last week on qualitative research, Jane’s thesis is another example of why this type of study needs to be done. This is an excellent doctorate. The data therein were carefully and sensitively generated, analysed and written up. Jane has already lead authored this paper, which appeared in the Journal of Advanced Nursing last year. Expect more to follow.

Sticking up for qualitative research

Technological failure meant I was unable to participate in this week’s Mental Elf campfire discussion, What has qualitative research ever done for us? The context for the event was the recent decision by the BMJ to reject a paper submitted for publication by members of the McGill Qualitative Research Group on the grounds that qualitative research reports are of low priority. This, the BMJ editors added, is because they are downloaded and cited less often than are reports of quantitative research. The BMJ communication conveying this news to the McGill team was posted on social media, triggering significant protest and then a letter to the BMJ making the case for qualitative methods and urging an editorial rethink.

These kinds of debates over the relative value of different research approaches flare up from time-to-time. Sixteen years ago Philip Burnard and I wrote a paper on the emergence of two camps within mental health nursing. We characterised these with reference to a quantitative/qualitative divide, and made a case for rapprochement and synthesis.

In the event, this week’s campfire which I missed was a sensible and informed one, with excellent speakers. The recording can be viewed here:

For the record, the exemplar piece of qualitative mental health research which I had prepared to talk about is Strauss and colleagues’ Psychiatric ideologies and institutions. I wrote a short piece about this book in 2014, on the occasion of its fiftieth birthday. My view remains that many of the observations made within it are as relevant now as they were in 1964. Ideas and practices, for example, remain contested.

Suffice to say that there has been no shortage of very high-quality qualitative mental health research produced in the years since, including by nurses. Check out these papers by two other invited campfire participants: Alan Simpson on the squeezing of community mental health nurses’ time, and Michael Coffey on the use of time in the accounts of conditionally discharged patients living in the community. Both show how the considered analysis of detailed qualitative data can reveal vital new knowledge of mental health systems, and of the views and experiences of people working within, or using, them. For readers wanting more, over on the Mental Elf website there are currently more than 200 blog posts on recent qualitative research: a rich repository indeed.

This week’s Mental Elf campfire discussion also included some commentary on the use of mixed methods. COCAPP and COCAPP-A demonstrate the value of combining quantitative and qualitative approaches, and reveal how data from surveys, interviews, observations and documentary review can be fruitfully brought together. This type of study is becoming increasingly popular, informed by the idea that different research questions (of a type which might be brought together in a single project) simply require different methods to answer them. This is a position I remain comfortable with.

And so we press on. I’ve been involved in lots of writing lately, as projects yield papers. As per my usual practice, as these appear in journals I’ll aim to write posts on this blog about them and include links to open access versions as I am able. Thanks for reading, and feel free to comment.

Fieldwork

FieldworkToday brought some interesting discussions on qualitative fieldwork, including on researcher roles and relations during data generation. First up was a COCAPP-A project meeting which included a conversation about observational methods in inpatient mental health settings. Second was a seminar led by Michael Coffey‘s PhD student Brian Mfula, drawing on his ongoing PhD experiences of ethnographic fieldwork centring on care planning and care coordination in forensic mental health care.

Brian shared his experiences of negotiating access, and of his reading and thinking about insider and outsider roles. This led to a wide-ranging talk amongst those present on fieldnotes and approaches to qualitative research (Grounded theory, anyone? Phenomenology? Or perhaps thematic analysis is more your thing?). We talked, too, about reflexivity, and knowing when (and how) to leave the field. Along the way this took us to the National Centre for Research Methods’ excellent Review Paper, How many qualitative interviews is enough?

Around ten years ago I contributed a chapter covering some of this territory to Davina Allen and Patricia Lyne’s edited book, The Reality of Nursing Research: Politics, Practices and Processes. Titled Data generation, this contrasted survey principles and practices in The All Wales Community Mental Health Nursing Stress Study with the ideas and methods in my (then-ongoing) ethnographic PhD, Health and Social Care for People with Severe Mental Health Problems. I wrote about decision-making, and the extent to which data are interactionally produced by researchers and participants together:

Whilst different strategies place different expectations and demands on nurse researchers, this chapter has also shown that – whatever approach is followed – data generation is always a purposeful activity demanding a reflexive stance. The principle of reflexivity underpins the idea that research always takes place in contexts, shaped to significant degree through an interaction between researcher and researched. The character of data produced in a study is moderated by aspects of the researcher’s personal biography and their interaction with research participants. This is a well-established principle in the social sciences. In nursing research, however, reflexive investigators have to give consideration not only to general biographical aspects such as age and gender, but also to their specific occupational backgrounds and practitioner experiences. A self-conscious, reflexive approach includes acknowledgement of the utility and the limitations of practitioner knowledge, and the implications of this for data production.

I’m now thinking that today’s seminar and discussions show how live these issues remain, and will ever remain so.

End of week catch-up

This week I learnt a whole lot more about framework analysis, having made the trip to City University London to join others in the COCAPP team for a NatCen training event. This was also my first introduction to the use of NVivo (a computer-assisted qualitative data analysis software package), my experience having previously been with Atlas.ti.

Elsewhere the RiSC project team convened, via teleconference, for an important decision-making meeting. We’re entering the closing stages of this study, and it’s interesting stuff: about which I’ll be able to say more in time.

And, as planned, this was also the week I made the short hop to Cardiff Met (at the invitation of Lynette Summers in the University’s Library and Information Services) to meet with folk there to talk about my experiences in using this blog, and other things, to bring my research and writing to a wider audience. That was fun, and I hope useful, too.

Along with some classroom teaching, marking, a committee meeting and reading a nearly-there doctoral thesis that just about sums up my recent workplace activities. Varied, as always. Looking ahead, I realise that (unusually) I’ll be missing the next meeting of Mental Health Nurse Academics UK due to take place at Lincoln University on February 18th. Other commitments have won out on this occasion.

‘Psychiatric Ideologies and Institutions’: 50 years and counting

Happy new year. In the midst of a series of holiday period email exchanges Michael Coffey happened to mention that 2014 marks the 50th anniversary of the publication of Anselm Strauss and colleagues’ Psychiatric Ideologies and Institutions.

This is a fine book indeed, which during my time as a PhD student concerned with work and roles in mental health care was an absolute essential. In it, Strauss and his collaborators reported findings from prolonged and intensive fieldwork conducted in two North American psychiatric hospitals. Whilst today’s qualitative research reports will typically include lashings of direct data extracts, Psychiatric Ideologies and Institutions has little in the way of what Strauss et al referred to as ‘illustration and quotation’. Yet I never once recall, as a reader, doubting that Strauss and his team were truly there, participating in and recording everyday hospital life and its organisation.

It is at this descriptive level that the book initially works: as a meticulous account of the interplay between ideas, professions and practices in an area of health care which (both then, and to this day) happens to be particularly contested. One part of the dataset drawn on in the book comes from a questionnaire, designed to capture information about affiliations to particular treatment ideologies. From this nurses emerge as being ‘ideologically uncommitted’. In a later, detailed, section Strauss et al wrote of the problems faced by nurses in reconciling their managerial, administrative and therapeutic tasks and in answering the still-pertinent question:

…at the heart of her professional identity: What does therapeutic action toward patients actually involve for a psychiatric nurse?

My copy of Psychiatric Ideologies and Institutions is the edition published in 1981, for which a new introduction was added. In this, Strauss and his collaborators wrote of their original ambition to produce a book which was not only descriptive, no matter how detailed or accurate, but which was also theorised. It was the fieldwork and the findings reported most completely in this monograph that gave rise to the idea of the negotiated order. This is a sociological theory of importance which, in the decades following its introduction, went on to develop a life of its own. As Strauss et al wrote in their 1981 introduction, their original observation that theory might emerge from data represented a considerable methodological departure, more fully articulated at a later point with the introduction of grounded theory. Here, then, is a second way in which Psychiatric Ideologies and Institutions works, and remains of interest to people unconcerned with research into the world of mental health care: as an exemplar of how data and theory can dance together.

Today I’ve turned up this review of the book, which appeared in 1965 in the journal now called Psychiatric Services. In it the reviewer sums up with the recommendation that:

All in all, most professionals will find this book profitable to read, study and think about.

I concur, and commend this classic text to professionals and others alike. And as an aside, perhaps this short celebratory post can help persuade students (usually undergraduates, in my experience) that books and articles which happen to be more than five years old can still be worth reading.

The accidental grounded theorists

On Friday I had reason to ponder the relationships between theory and data, and the boundaries between different types of qualitative research. This was day two of my Working and Leading in Complex Systems professional doctorate module. What I discovered is that I may, in fact, have become an accidental grounded theorist. Or possibly not…I’ll let the reader decide.

During a talk about critical junctures I said how, in our recent paper, Nicola Evans and I had elected to lay out our theoretical contribution (i.e., our idea of ‘critical junctures’ as pivotal, punctuating, moments initiating or taking place within longer individual trajectories of care) ahead of displaying our data. We had done this even though our ‘theory’ had in fact been fieldwork-driven, as we then demonstrated in our article with extended, illustrative, extracts. Quite reasonably, in the classroom I was asked if we had therefore used a grounded theory approach.

This question got me thinking. My immediate response was that Nicola and I had developed a concept from empirical data but had absolutely not claimed to be ‘doing grounded theory’. In fact, the thought had never occurred to us (or to me, at any rate).

And there’s the nub of it. What does it actually mean to ‘do grounded theory’? Follow a stepwise recipe from a methodological cookbook? Or range freely over one or more sets of data in the search for new insights? Without wanting to suggest that ‘anything goes’ in terms of methods, I wonder if we can sometimes get too hung up on techniques and ‘rules’ when it’s the principles which really matter? In our critical junctures paper these included a commitment to the inductive ‘drawing out’ of conceptual insights from an analysis of talk and action. They also included the idea of staying close to our data, and of offering fieldwork extracts in support of the theory. I personally have no wish to agonise over what flavour of ‘doing qualitative research’ we have done here, and I’m also not sure that all of the finer distinctions and sub-divisions necessarily matter or even make sense.

But perhaps I’m missing something.