Nurse-Educators Communicative Competence - Assignment Example

FRAMING QUALITATIVE RESEARCH This paper sets to discuss the application of qualitative methodology in nursing research. Based on the nature of study objectives, two interpretive methods namely phenomenology and grounded theory (GT), and a critical method of inquiry – ethnography – have been selected for the purposes of this discussion. Reiter, Stewart, and Bruce (2011) propose three intervening factors for selecting a research methodology: the research setting, the research question and the mode of generating data. Three research questions based on perioperative patient teaching will guide the discussions the method’s on selection criteria, theoretical underpinnings, and anticipated data. The general acceptability and application of qualitative methodology in social research cannot be overemphasized. Qualitative nurse research locates itself within the social context – studies, makes sense of and interprets phenomena in their natural settings (Denzin & Lincoln, 2011). However, questions of hierarchy of evidence in relation to qualitative methodology and whether it measures up to the positive constructs of what constitutes good research continue to dog qualitative research in health sciences (Flemming, Closs, Foy & Bennett, 2011). To strengthen nursing in terms of evidence base, should nursing research consider abandoning qualitative methods for methodologies that are high in the hierarchy of evidence? In effect, qualitative methodology is sometimes marginalized and underutilized at the expense of quantitative methodology that some researchers perceive to be more ‘more scientific’ (Carlson, 2010). This argument, though ‘scientifically’ good sounding, if embraced, would serve to impede rather than expand the scope of the profession owing to social issues in nursing that can only be exhaustively studied by qualitative research designs (Jirojwong, Johnson & Welch, 2011). A clearly constructed qualitative research provides accurate data about the experiences of health services recipients in cases where formulation of hypothesis is insufficient (Jones, 2012). This paper, therefore, has formulated three research questions on perioperative teaching that can be sufficiently studied by qualitative research. 1. a) Problem statement The social distance between the nurse and the patient determines the acceptability of perioperative teaching. b) Research question How does the social group identity affect the process and outcome of perioperative education? Patients admitted to hospital for a surgical operation undergo a lot of emotions that might adversely affect the recovery process (Wong et al 2010; Mitchel, 2010). Postoperative stress can be both physical and psychological (Levender & Feldman, 2011). Adequate patient information ensures patient preparation, confidence, and involvement ( Taylor, 2011). The education session informs and empowers patients (Johansson, Katajisto, & Salanterä, 2010). Patients’ adherence to guidelines on preoperative fasting significantly improves (Kyrtatos, 2014). Studies have shown that patients who attended a preoperative teaching session were hospitalized for a shorter duration and coped better with postoperative pain than those who didn’t undertake any preoperative education (Hong & Lee, 2012). Research in perioperative instruction should now shift focus to ways of improving the efficacy of perioperative education by studying its predictors. At the heart of the process of medical education is the social group identity (Burford, 2012). It can be hypothesized that the closer the patient identifies with the nurse conducting preoperative education, the greater the influence of this education on the patient. To validate this proposition, institutional ethnography (IE) is proposed as an effective methodological design. Group identity is essentially a socio-cultural matter, and IE is constructed around understanding people and those around them. IE has been described as a “reflexive-materialist, qualitative method of inquiry” (Hussey, 2012). The term ‘institutional ethnography’ emphasizes an explicit connection between power structures – institutions – and everyday experiences and practices of at the local levels – ethnography (Appelrouth & Edles, 2011). This critical social inquiry method was founded by Dorothy Smith in the 1970s (Adams, Carryer &Wilkinson, 2015). The philosophy of IE is about exploring and emphasizing the relationship between the daily experiences of people and the social world as constructed by institutions. Theoretically, IE recognizes that a person’s experiences and knowledge of everyday life are not necessarily the same as the institutional or the authorities’ construction of one’s world and work (Bisaillon, 2012). The hard reality, however, is that one’s social world and daily activities are controlled by the authorities. Lowndes, Angus & 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 would find texts and artefacts like drawings and diary entries reliable sources of data (Trede & Loftus, 2010). 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). 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). Applied to perioperative teaching and social identity, IE would reveal how the institutional programmes for patient information might contradict the localized expectations of both the nurse educator and the instructed patient. Nurse researchers value ethnography for widening the understanding of health issues in cultural contexts (Cruz & Higginbottom, 2013). Institutional ethnographers would generate diverse and complex data relating perioperative teaching to social identity since this methodology applies multiple perspectives on a single social phenomenon. For example, information on shared experiences that facilitate positive interaction between the nurse teacher and the patient is useful for measuring the efficacy of preoperative instruction from a socio-cultural rather than an institutional standpoint. Data from IE can be used to correlate culturally interpreted variables like gender, race, religion, education, socio-economic status and related demographics with the institutional expectations and assignments. Researchers have used IE to explore and determine how institutional forces on shape health workers’ experience (Moll, Eakin, Franche & Strike, 2012) Discrepancies between the constructions of the social worlds may greatly influence the outcome of perioperative pedagogy. Bisaillon & Rankin (2012) maintain that an IE inquiry needs to go through the ‘taken-for-granted’ data about people’s practices; consider contradictions and tensions underpinning these experiences; and identify clues on relations that connect these experiences. They explain that the institutional ethnographer’s outcomes go beyond interpretation to arrive at “faithful representations about what goes on in people’s lives.” 2. a) Problem statement The best practices in preoperative teaching are indicative of its direction and outcome. b) Research question What best practices in preoperative teaching are nurse-specific? Three surgical phases constitute preoperative episode: preoperative, intra-operative and postoperative. Patient assessment and education in the preoperative phase are prime responsibilities of perioperative nurses making them the leading change agents and teachers in the perioperative process (Ali, Lalani & Malik, 2012). Levender and Feldman (2011) identify the general objectives of preoperative teaching: inform the patients about their medical condition; prepare the client for surgery and post-operative care; and ensure the patient’s compliance to a treatment regime. Providing sufficient information preoperatively and postoperatively as well as safe follow-up will greatly shorten the length of admission and reduce chances of readmission (Varadhan et al., 2010). Good patient preoperative education also improves the patient’s satisfaction levels (Ruiz Ortiz et al., 2013). Aasa, Hovbäck & Berterö (2013) studied the experiences of a patient during preoperative teaching as a component of the Enhanced Recovery After Surgery (ERAS) concept. The study found five themes from the patients’ experiences: participation, trust, being seen, security and responsibility. As a follow-up to these findings, there is need for a study that matches preoperative teaching practice with the specific expectations pointed out in the ERAS study. Findings from this kind of research would help refine the teaching manual, the teaching methodology and selection of the nurse-educator. The grounded theory (GT) approach would avail useful outcomes for this study. Gelling (2011) and Hall, Griffiths & McKenna (2013) observe that nursing research often use GT methodology. It is an effective method of inquiry for studying human action and human interaction (Cooney, 2010). The essence of GT is in the formulation of a theoretical construct grounded in empirical data (Engward, 2013). The data must be systematically collected and scientifically analyzed (Ramalho, Adams, Huggard, & Hoare, 2015). The developers of the grounded theory, Glaser and Strauss, created a system through which data was simultaneously collected and analysed (Birks & Mills, 2011). Whether classical, evolved or constructivist, GT’s methodological goal is to develop a theory grounded in data and not to test a hypothesis (Ramalho, et al., 2015). It follows that before data collection and analysis, the researcher need to conduct literature review (Dunne, 2011; Giles, King & de Lacey, 2013).This helps the researcher to bring to research the knowledge acquired from previous inquiries (Corbin & Strauss, 2015). Contrary views, however, hold that reviewing literature beforehand may allow the existing theories to impose themselves on data analysis and prevent the resultant theory from being solely grounded in, and emergent from, the data (Walls, Parahoo & Fleming, 2010). Theory formulation concerning preoperative instruction and the realization of its objective must take into cognizance all the elements in patient pedagogy. The ERAS study cited above found that the nurse teachers gave too much information within a limited time, some nurses never listened to the patients while others did not have sufficient information on medications, meal restrictions and surgical procedure (Aasa, et al., 2013). Apart from these concerns, other intervening factors include the medium of instruction, and the nurses’ availability, professional training and daily workload (Lee & Lee, 2012). To obtain desired results, the process of theory grounding involves constant comparison, a tool that emphasizes reflective thinking (Giles et al., 2013; Dunne, 2013). Good practice in preoperative teaching should be grounded in theory, and good theory is grounded in empirical data. 3. a) Problem statement The achievement of the goals of perioperative patient education significantly depends on the educator’s communicative competence. b) Research question What aspects of the nurse-educator’s communicative competence directly affect the achievement of the instructional objectives? Miscommunication between the patient and caregivers can break down the surgical and recovery processes. Liebner (2015) noted low levels in general and medical literacy among the patients. It is necessary to work towards overcoming linguistic barriers in patient education. (Weldon, 2014). The guiding principle is to ensure that patient information is thorough and easily understood (Younis et al., 2013). A phenomenological study of the communicative competence of the nurse educator will reveal its instructional impact on the perioperative process. Ali, Lalani and Malik (2012) recommend assessment of the communication mode and the patient’s literacy levels before teaching them. Phenomenology has been recommended for investigating a practitioner’s experiences as well as strengthening nursing research (Wilson, 2014). It has particularly enabled new insightful inquiry into some profound nursing roles like critical care (Folkmann & Rankin, 2010). The strength of phenomenology lies in its philosophical claim to a firm epistemological and ontological grounding of its findings and data. Grace and Ajjawi (2010) linked methodological advantages of phenomenology to its contextual and subjective portrayal of human experiences. Nursing researchers who choose a phenomenological methodology – whether Heideggerian or Husserl’s – contend with how to express a research question in a suitable ontological and epistemological terminology (Titchen & Ajjawi, 2010). An ontological question asks about what nurses are supposed to be (the being) in a given care situation rather what they know (the knowing). The latter is an epistemological concern. This challenge can be overcome partially by embedding meaning in practices through shared or constructed language. Higgs and Trede (2010) thus suggested a hermeneutic phenomenology that is constructed around being in the world and sharing experiences. Phenomenological interpretation must get into the ‘hermeneutic circle’ to share, understand and interpret experiences. The three modes necessary for phenomenological interpretation include absorption in practice, observance of the practice and contemplation of the practice (Wilson, 2014). A study of the educator’s communicative competence in a perioperative oral teaching environment would generate useful outcomes. Transcripts of the teaching sessions are aligned with the shared experience among the researcher, the nurse educator, and the patient. Intuitive data gained through pre-reflective experience and contextual features also help in creating themes and making phenomenological descriptions. The challenges posed by incomprehensible linguistic forms like medical terminology; long, compound and complex sentences; and ambiguous or distractive non-verbal in voice quality and body language of the nurse educator would form useful data for phenomenological interpretation. Interpretation is done what the nurse needs to be and what she needs to know in the perioperative teaching process. In spite of reservations about qualitative methodology concerning the hierarchy of evidence, it can be demonstrated that qualitative research design is capable of availing the most reliable data on social phenomena in healthcare. To this end, qualitative nursing researchers have to fuse theory with method so as to reach a comprehensible study design. In this paper the three qualitative methodologies selected – ethnography, grounded theory, and phenomenology – have been theoretically and empirical analysed to make the connection between data sought and methodology explicit. Two socially contextualized issues in perioperative teaching namely social identity and communicative competence present a good premise for ethnographical and phenomenological inquiry respectively. The best teaching practices was found to fit a grounded theory methodological approach. Evidence that can be mined from a research enterprise is of no significance if its findings are intangible in terms of practice. The strength of the three qualitative processes in question is in the type of conclusions they generate. The themes and propositions from these theories are readily actionable upon by practitioners in the nursing profession. A good example is the ERAS study whose outcome clearly spelt out how preoperative patient teaching should be refocused (Aasa, et al., 2013). References Aasa, A., Hovbäck, M., & Berterö, C. M. (June 28, 2013). The importance of preoperative information for patient participation in colorectal surgery care. Journal of Clinical Nursing, 22, 1604-1612. Adams, S., Carryer, J., & Wilkinson, J. (January 01, 2015). Institutional ethnography: An emerging approach for health and nursing research. Nursing Praxis in New Zealand Inc, 31, 1, 18-26. Ali, R., Lalani, N., & Malik, A. (2012). Pre-Operative Assessment and Education. Surgical Science, 03(01), 10-14. doi:10.4236/ss.2012.31002 Appelrouth, S., & Edles, L. D. (2011). 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