Orthopaedic Patients Experience in Perioperative Teaching as Reflected in Patient Satisfaction Surveys - Research Paper Example

Introduction Orthopaedic patients’ experience in perioperative teaching as reflected in patient satisfaction surveys This paper seeks to develop into a research proposal, one of the research questions constructed in the previous assignment. The proposed study employs a qualitative methodology which will be justified against the background of the relevant philosophical and theoretical underpinnings. The discussion of the research methods right from sampling techniques to data collection, management and analysis are followed by an examination of issues of ethics and rigour. The proposed study will employ institutional ethnography (IE) to explore the perioperative educational experiences of the orthopaedic patients as reflected in the patient satisfaction surveys. Patient satisfaction surveys have been used “successfully” over time for assessing a variety of nursing roles as well as good patient engagement (Lam, Yuen, Mercer & Wong, 2010). In Australia, Desborough, Banfield and Parker (2014) developed PESS – Patient Enablement and Satisfaction Survey – for evaluating nursing care locally. Halcomb, Caldwell, Salamonson and Davidson (2011) have claimed that patients in Australia have reported high measures of satisfaction with nursing care. The planned study questions the patient surveys’ efficacy and the authenticity of their conclusions. It has been noted that these self-reporting business-like surveys about client satisfaction, though in common usage, may obscure and distort the actual experiences of the patients and nurses, making such surveys an insufficient ground for corrective measures (Al-Abri & Al-Balushi, 2014). To get to the core of actual patient experiences of healthcare, surveyors need a critical approach that aids in understanding the realities constructed around subjective experiences that cannot be measured by quantitative methods. To address this gap, IE has been selected for the proposed study to provide an understanding of the actualities of patients’ satisfaction with the perioperative teaching in spite of what they report in the conventional surveys. Methodology Institutional ethnography has been described as a “reflexive-materialist, qualitative method of inquiry” (Hussey, 2012). This qualitative inquiry is designed for discovering and/or exposing social control in an institution by analysing textually mediated social discourses (Adams, Carryer & Wilkinson, 2015).The critical social research method was founded by Dorothy Smith in the 1970s who used the term ‘institutional ethnography’ to emphasize an explicit connection between power structures – institutional – and the everyday experiences and practices of people at the local levels – ethnography (Appelrouth & Edles, 2011). IE inquiry applies data collection methods consistent with qualitative methodology notably observation, interview and textual analysis and it aims at constructing an empirically sound argument based on practices that occur in institutional settings (Bisaillon & Rankin, 2012). Three philosophical constructs embody the IE inquiry: epistemology, ontology and recursivity. Bassailon (2012) explains that epistemology which is a principle of knowledge refers to the way we know what we do know about the world. An ethnographer seeks answers to questions like “How does one come to know what they know?” Hart and McKinnon (2010) identify two distinct ways of knowing namely knowing objectively (ideologically) and knowing subjectively (experientially) the latter of which is the concern of institutional ethnographers. They strive to understand the experiential knowledge by making explicit the social relations and social organizations. The guiding principle here is that people’s lives are socially organized and so is what they know. Research drawing from the epistemological philosophy of IE examines social problems with a view of identifying and explicating how the problems are socially organized and the trans-local social relations coordinate and arrange people as they experience these problems. Ontology, the principle of the nature of existence refers to how knowledge is constituted. Embedded in the Marxian ontology is the view that individuals are real and they relationally produce their own conditions of existence as well as their knowledge. Knowledge is thus socially constituted. The ontological perspective guides IE textual analysis. An IE inquiry has to locate the ‘something else’ embedded in the texts (Hart & McKinnon, 2010). Textual analysis in the Smithian sense, therefore, offers clues that locate the framing of a given text, in our case the patient satisfaction survey forms, within a social organization. This perspective views lives as being organized into knowledge forms that force people and events to be managed through a specific bureaucratic practice – Smith calls this phenomenon ‘ruling’. In analyzing the patient satisfaction text, for example, the IE investigator must discover what the patient survey accomplishes within the managerial agenda of the hospital. GW Smith introduced the concept of recursivity which helps to trace social relations in discursive sites (Deveau, 2011). Recursivity means that texts actively constitute social relations and can iterate organizational configuration at different times and places. This implies that texts are just but a ‘story within a story’; hence, they tell only part of a larger story which the ethnographer must locate. This study will attempt to decipher the larger ideological institutional construction of the patient-centred care embedded in the satisfaction surveys. The theoretical foundations of IE are located in the Marxist thought (Tomba, 2013). Marx’s materialist theory, upon which IE is premised, posits that one’s knowing of something is organized by social forces and relations that one may not be conscious of (Deveau, 2011). Three assumptions emerge from this standpoint. Firstly, people live their own lives in the best way they can. Secondly, subjects are found in local settings throughout the society. And lastly, powerful external (trans-local) forces determine the way people live and experience everyday lives. The trans-local forces are, according to Smith, called ruling relations that coordinate and co-order the actions and the activities of people across various multiple local settings. IE helps marginalized people to understand their localized experiences within a broader context. It accomplishes this by mapping the powerful forces that operate from afar to hook the local into the trans-local relations of ruling. In this way, the product of IE is a social cartography that can help the marginalized and their advocates to understand, challenge and even transform these powerful forces. Ruling relations can also be understood as textually-mediated social relations – the progression of interdependent actions shaping the people’s daily practices. This study as a materialist inquiry project will start within the circumstances of the patients’ lives, their actions, their experiences and end with their actualities; that is, the concrete world of the people’s actual activities and practices (Bissaillon, 2012). The understanding is that these circumstances are produced socially within certain historical, political and economic contexts that are best interrogated through materialistic investigations like IE. The philosophical and theoretical underpinnings will guide the proposed study to grasp both the power mechanisms at play in the hospital or the orthopaedic ward and how it extends into the patient’s knowledge as reflected in the patient survey. Lowndes, Angus and Peter (2013) outline three tasks in IE research: identifying the localized practices and experiences; studying the institutional instructions and discourses; and mapping social relationships. The ethnographer finds texts and artefacts like drawings and diary entries reliable sources of data (Trede & Loftus, 2010). The text of interest in this study, the patient satisfaction surveys, will form the basis of discovering the social processes that constrain practices of service evaluation in perioperative wards. Preference for IE is evident in its adoption by an emerging body of nursing researchers from North America exploring the incorporation of authoritative knowledge into institutional systems to control and determine what nurses do in clinical settings (Folkmann & Rankin, 2010; Hamilton & Campbell, 2011). Another team of ethnographers used IE to study nursing students’ evaluation (Rankin, Malinsky, Tate & Elena, 2010). In the proposed study, institutional ethnography will allow the researcher to explicate the relationship between textual practices with the people’s experiences in everyday life through the paradigm of social relations of ruling. According to Hamilton and Campbell (2011), IE opens up for investigations, aspects of power operations in social life that are erstwhile hidden and mysterious. It has been used to explore and make visible the relationship between experiences of people and their everyday activities and the institutional construction of the social world. The mundane and routine experiences are problematized and the deliberate organization of this knowledge is uncovered. It has been noted in some instances, like in my centre, that patients may give similar responses in these patient feedback surveys in spite of their varied periopoerative experience. It is important to unearth the social tensions underlying these responses. Data gathered from the patient satisfaction surveys should be accurate as it reflects care delivery by nurses and physicians and serves as a basis for learning and management decisions for improving healthcare services (Petrullo, Lamar, Nwankwo-Otti, Alexander-Mills & Viola, 2012). Method The central components of any research design are the formulation of the research topic and selection of methods to study it (Denzin, & Lincoln, 2011). Sampling and recruitment techniques are described generally in institutional ethnography and particularly in regard to this study. The same will be done for data collection, management and analysis strategies. Sampling Marshall, Podda, Fontenot and Cardon (2013) observe that effective sampling is the key to making sound empirical generalizations from studies. Ethnographers make a distinction between interactive and non-interactive sampling, the former of which becomes the standard for analysing natural interaction. Fetterman (2010) asserts that the research question shapes the selection of the place, the people and/or the progamme to study. Typically, ethnographers would use the big-net approach – mingling and mixing with everyone at first – which is conducive to participant observation. Judgmental sampling is, however, the most common and natural technique for ethnographers. Experienced ethnographers may employ a rigorous randomized sampling strategy at the beginning especially when they have sufficient knowledge about the unit or culture under study. However, the use of highly structured randomized designs may prematurely narrow the researcher’s focus thereby eliminating participants that are very relevant to the study. This study will employ judgmental sampling to select the place of the study (postoperative orthopaedic ward) and a randomized sampling design to select the patients. The patients in the postoperative ward are the best placed to provide feedback on their perioperative education experience. The orthopaedic unit has been selected because orthopaedic patients and nurses, by virtue of their unique problem, have unique experiences (McLiesh, 2012). Fetterman (2010) points out that the events in the field vary with time and it behooves the researcher to either to set the time for fieldwork or to sample. This study sets the time for the field study and hence the study population includes all the surgical patients admitted in the orthopaedic unit within the first two weeks of the field study out of which a sample of 25 patients will be selected. Marshall, Podda, Fontenot and Cardon (2013) suggest 20 to 30 participants for qualitative health research. The extra five participants above the minimum will take care of dropouts generally estimated at 12% (Hoerger, 2010). From the sample, up to five articulate and sensitive participants will be selected on the basis of the depth of their responses as Key Informant Interviewees (KII). As excellent sources of information, the key informants participate in providing concrete descriptions and corroborate information gathered from the basic interviews (Fetterman, 2010). Recruitment Recruitment of the participant is an integral phase of any research enterprise as the study can hit a dead end if a community is disinterested in the ethnographer or the work. Fetterman (2010) suggests that the ethnographer’s best ticket into a community is to be introduced by a credible community member. Securing the group’s trust strengthens the researcher’s capacity to work with the group hence improving data quality. For the proposed study, the researcher will be introduced to each patient by the care giving nurse. It is assumed the nurse and the patient have established high rapport and confidence levels. The researcher will first peruse the admission records to establish eligible participants. Only patients who received preoperative teaching and underwent surgery in this facility will be included in the study. The patients that meet the criteria for inclusion will be verbally requested to participate and asked to give a written consent. To be excluded from study are patients who may be unable to participate in the interviews. They include children, non-English speakers and patients with co-morbid conditions. Data collection and management Three data collection strategies are generally employed by ethnography: participant observation, interviews and examination of documents (Cruz & Higginbottom, 2013). Participant observation is an opportunity for the researcher to get involved in the participants life experiences in their natural settings thereby becoming immersed in the immediate culture under study (Denzin, & Lincoln, 2011). In this inquiry, the researcher will employ participant observation to get familiar with the social relations and power structures in the ward and bedside subcultures. Two paradigms for participant observation can be outlined namely the pure and the varied. Two situations are possible in the pure participant observation: a new role in an unfamiliar setting or a familiar role in a new setting. In the varied paradigm are two possibilities: new role in a familiar setting or a familiar role in a new setting. In the proposed study, the researcher is a nurse in the hospital in which the study is located and will hence employ pure participant observations. As much as the researcher lives the life of the people under study, maintenance of a professional distance will allow adequate observation and recording of data (Fetterman, 2010). The proposed study will conduct individual as opposed to group interviews to gather information in the patients’ experiences using formal and informal interviews. Formal (structured) interviews ask specific questions and seek explicit goals while semi-structured interviews seek explicit goals by asking specific goals but they give room for digression from the topic. Informal interviews adopt casual conversational strategies with implicit research agenda (Trede & Loftus, 2010). In addition, the planned study will employ retrospective interview by asking the patients to reconstruct their preoperative teaching experience. The interview guide will comprise three forms of questions: survey or grand tour questions for eliciting the broad picture (global view) of the participant’s world for mapping the cultural terrain, structured questions and attribute questions about their understanding of the social structure around them. In all cases, the researcher will strive to observe the interviewing protocols by being natural, honest and focused on learning from rather than impressing the interviewees. The final data collection strategy to be implemented is the study of documents. Lowndes, Angus and Peter (2013) have noted that collecting and analyzing documents can aid in understanding the community and in validating interview findings and participant observations. For this study, hospital records of staff portfolio, duty schedules and the patients’ biographical entries, admission, progress notes and, most importantly, patient satisfaction survey forms will be scrutinized. While the patient satisfaction documents constitute the mediated texts, the other records and other data collection strategies will shed light on the embedded social relations. Data gathered from other sources is used to test the fidelity of the patient surveys in capturing the actualities of the patients’ experience in the perioperative teaching episodes. The patient surveys come in form of questionnaires which the patients activate and fill online. As described in the PESS, the standard practice in most hospitals is to have the surveys accompanied with an introductory letter and a summary report (Desborough, Banfield & Parker, 2014). These three documents provide important cues for social organization and the institutionalized shaping of patient satisfaction survey. The survey usually asks an average of 50-100 questions categorized into subtopics like Communication, Relationships, Daily Care and so on with each question having predetermined responses in the Strongly Agree – Uncertain or Excellent – Poor scales. The responses from all the discharged patients are aggregated into a computer-processed statistical ‘virtual reality’. The planned study will focus mostly on the items touching on the patients experience in perioperative education. Data analysis Denzin and Lincoln (2011) observe that ethnographical data analysis is continual and multistage as it involves various data collection levels and different forms of data. In the case of the planned study, data will be selected from three main sources: participant observation, interviews and patient survey forms. Raw data comes in form of notes, transcripts and verbatim responses. The researcher listens to the recorded interviews and transcribes them every evening. The transcriptions are read through and through so that they can be sorted or grouped first in big piles then into smaller piles. Iterations of themes are discovered as the working is continually reworked. Sorting is facilitated by indexing the verbatim transcripts by using continuous numbering. Each indexed entry is coded using English words or abbreviations, different colours, flagging or cutting and pasting related responses. Irrespective of the coding format; analytical coding should be embedded in the study hypotheses. Data from the field will also be analysed through narratives that address specific themes. Manifestations of the cultural and sub-cultural patterns under study will emerge. Cross-checking of the data is important to obtain the most reliable interpretation. The researcher is advised to return to the whenever there is need to ground the truth. Data analysis will adopt the Method of Agreement by describing what is common across the case, the Method of Difference, describes what is different and how while the Negative cases will stand on their own. The researcher will also adopt the event-structure analysis (ESA) in which perioperative teaching episode will be considered as an event whose analysis can reveal the embedded social power relations. Ethical Considerations The ethical risks associated with study arise from the participant characteristics. The participants are patients and hence measures must be taken not to infringe on their rights as this may jeopardize the study process, outcomes and acceptability. In accordance with the National statement on ethical conduct in human research (2007, Revised 2015) all the participants will receive oral and written information about the project. Their informed consent to participate in the study will be sought for and received in writing as per the Australian Code for the Responsible Conduct of Research. The researcher also shared the following information with the participants: The steps they will follow during the research The possible merits and demerits of taking part in the study The researcher’s credibility Upon obtaining their consent, the researcher will request the participants to sign consent forms and inform all of them that they are free to withdraw from the study, if they so wished, at any stage. This will make the participants give voluntary and informed contributions in the project, a requirement by ethical bodies in Australia. The researcher will assure the participants of the confidentiality of their contributions and the anonymity of identity. This means that their names will be unidentifiable in print. The participants will be asked to sign a written statement declaring that they would maintain the confidentiality of discussions. Furthermore, the interview recordings and photographs will be done with the full knowledge and consent of the participants. In addition, the researcher will make the participants aware of their right to decline to respond to a question (if they so wished) and to decide which information they are/aren’t willing to give. In this regard, the researcher will conduct the study in a competent manner by following the advice that the researcher remains sensitive to the participants’ needs, maintains objectivity, and avoids making value judgments of participants even if they sharply contrast with his/her values (National Health and Medical Research Council, 2015). The ethical provisions for this project will be formally reviewed by the relevant research and statutory institutions. Rigour and reliability Coker et al (2013) identify six key areas to be considered when assessing rigour in observational methods: observer, observations, choice of participants, data sources, comprehensive data collection, and data analysis as well as corroboration of findings. These will be considered in the proposed study to ensure rigour. The researcher (observer) will adopt an emic or insider approach and set aside prior assumptions so that themes and patterns would be allowed to emerge from data. DeWalt and DeWalt (2011) suggest that data should have multiple sources and be observed in real time. Triangulation facilitates validity of the study. When the same information is collected and analysed through multiple ways, the internal, construct and external validity of the study is enhanced. To ensure data reliability, iterative or concurrent collection and analysis will be done (DeWalt & DeWalt, 2011). The researcher will apply three strategies to corroborate findings: going back to the raw data for clarifications, going back to the field (the KII) to ground the truth of the findings and using another researcher conversant with ethnographical studies to assess the data quality (peer review). Conclusion Institutional ethnography as a qualitative method has been used to obtain data in nursing research that are important to nursing practice yet the data cannot be obtained by quantitative methodology. A good example is patient satisfaction surveys which use quantitative methods to generate data that are aggregated by computer software to provide a basis for improving healthcare services. Literature reviewed in this study reveals that such data may be misleading since the patient responses are constrained by social relations informing the constructions of these surveys which the surveys cannot measure. The surveys have been found to force patients to provide answers in a manner that does not reflect their true experience in the hospital since the surveys have preconceived responses like Strongly Agree, Agree, Disagree, and Strongly Disagree. The institutional social power relations embedded in the patient responses to the survey items can be effectively studied by IE since conducts a textual analysis with an aim of detailing social clues that locate the framing of the text. For the proposed study, institutional ethnography views the patient surveys as serving the managerial agenda and the patient is caught up in the socio-cultural power matrix. And the patients respond to the items in the survey for the purposes of serving the interests of the management rather than freely expressing their true experiences in the hospital. To go beyond interpretation to arrive at “faithful representations about what goes on in people’s lives” (Bisaillon & Rankin, 2012), the proposed study will adopt multiple data collection and analysis strategies (triangulation) which will not only improve the quality of the resultant data, but they will also be important in meeting the criteria for rigour and reliability. Data collection and analysis methods like emic or the insider perspective and iterative theme explication, for example, have been considered as effective indicators for vigour (DeWalt & DeWalt, 2011). It is hoped that this methodology will explain the discrepancy between the actual perioperative experiences of the patients in the orthopaedic unit and what the patients report in the satisfaction surveys. The findings of the proposed study will provide a more reliable basis for improving perioperative teaching than the aggregated data from the traditional patient surveys. 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