Critical realism and constructivism: merging research paradigms for a deeper qualitative study

Purpose

Traditional approaches in qualitative research have adopted one research paradigm linked to an established typology. This paper addresses the unconventional application of two research paradigms in one study. A critical realist approach was used to augment a constructivist analysis of data in a research project seeking to explore the meaning that managers in small to medium enterprises (SMEs) attach to hazard identification, the construction of a hazard profile reflective of the business and its use in assisting to manage hazards within the SME's safety management system framework. Critical realism offered a complementary but essential framework to explore causal mechanisms that led to a deeper understanding of the findings by searching for the processes and causality that lay beneath the social and organizational phenomena observed.

Design/methodology/approach

This paper compares the two research paradigms in order to seek junctures and apply them to a research project. Analytical tools applied to each research paradigm within the project are presented, followed by a new multiparadigm conceptual model that integrates critical realism and constructivism, providing an original contribution of knowledge to this field of qualitative research.

Findings

The adoption of a multiparadigm model enabled not only the interpretation of social phenomena but also the determination of its causality, enabling a more insightful answering of the research question and leading to a deeper insight into the phenomenology that was studied. This research approach widens the boundaries of qualitative inquiry within organizational research by promoting strategies that challenge more traditionally anchored research typologies, and consequently contributes to better research outcomes.

Research limitations/implications

This study was conducted across four organizations. Similar research is encouraged across a greater number of case studies to validate the process of using a constructivist and critical realist paradigm to gain a more insightful understanding of events and their causality.

Practical implications

The comparison of two research paradigms and consequent provision of a conceptual model (Figure 3) provides potential for the development of further multiparadigm models for research projects within the field of organizational management.

Social implications

This paper has the potential to promote engagement and collaboration between research scholars seeking to explore the use of multiple research paradigms.

Originality/value

Such an approach has not previously been widely discussed or adopted to examine qualitative data, and advances theory in qualitative research. The application of two research paradigms using such an approach can be applied to businesses in a number of different contexts to gain a more insightful understanding of research participant perspectives, observable events arising from those perspectives and their associated causality.

Clinical teams' experiences of crowding in public emergency centres in Cape Town, South Africa

INTRODUCTION

Crowding is a significant challenge for emergency centres (ECs) globally. While South Africa is not alone in reckoning with high patient demand and insufficient resources to treat these patients; staff-to-patient ratios are generally lower than in the Global North. The study of crowding and its consequences for patient care is a key research priority for strengthening the quality and efficacy of emergency care in South Africa. The study set out to understand frontline staff's perspectives on crowding in Cape Town public ECs to learn how they cope in such high- pressure working conditions, determine what they see as the factors contributing to crowding, and obtain their recommendations for reform.

METHODS

This research is a qualitative study from interviews and observations at five ECs in Cape Town, conducted in June and July 2017. In total 43 staff were interviewed individually or in pairs. The interviews included physicians of varying levels of experience (25), and registered or enrolled nurses (18). Data were analysed with the qualitative text-analysis software NVivo.

RESULTS

Both doctors and nurses saw crowding as a consequence of three factors: 1) limited bed space in the EC, 2) insufficient health professionals to care for admitted patients, and 3) the presence of boarders. Systemic or organizational factors as well as human resource scarcity were determined to be the key reasons for crowding.

DISCUSSION

With its high patient acuity and volume and its limited human and material resources, South Africa is an important case study for understanding how emergency care providers manage working in crowded conditions. The solutions to crowding recommended by interviewees were to expand the EC workforce and to add discharge lounges and examination tables.

The Development of an Accreditation Framework for Continuing Education Activities for Pharmacists

Accreditation is the recognition that an educational activity meets certain standards. The processes for accreditation vary considerably depending on the type of activity, and currently there are differing accreditation systems in place for pharmacy continuing education (CE) across different countries. Research was carried out on a selection of these systems with the aim of developing a catalogue of accreditation approaches, and exploring the possibility of developing a common framework for the accreditation of pharmacy CE activities. Accreditation processes from the countries represented by the Global Forum on Quality Assurance of Continuing Education and Continuing Professional Development (GFQACE) were reviewed to explore the themes and patterns in them. This informed the development of a proposed accreditation framework for CE activities for pharmacists. A Delphi method over four rounds involving seven participants from each GFQACE organisation was used as a consensus building technique. Agreement was achieved on including 15 items in the framework within four stages (Input, Process, Output, and Quality Improvement). The GFQACE steering group indicated their intention to use the resultant framework as the basis for the exploration of mutual recognition of accreditation between member countries.

Using patient companions as interpreters in the Emergency Department: An interdisciplinary quantitative and qualitative assessment

OBJECTIVES

To explore the perceived and actual quality of communication and the conversational mechanisms through which misunderstandings arise in linguistically diverse Emergency Department consultations.

METHODS

A mixed method approach was used, based on audio-records of consultations which rely on patient companions for linguistic support, and ethnographic contextual data. Interpreting errors and their potential impact on the clinical reasoning process and doctor-patient relationships were quantitatively assessed. Complementary qualitative ethnographic research provided a richer understanding of the context. The study involved interdisciplinary collaboration with specialists in applied linguistics, medicine, and psychology.

RESULTS

Accurate interpretation occurred in as few as 19% of interpreter speech turns. Answering for the patient and omitting information were the most frequent errors. The nature and severity of the impact of the errors varied. Answering for the patient had the greatest clinical impact. The omission of messages from the doctor to the patient negatively affected doctor-patient relationships.

CONCLUSION

Gaps were observed between the perceived and the actual quality of communication, although patient companions often provided useful information.

PRACTICE IMPLICATIONS

In addition to raising awareness among doctors on the potential risks of using AHIs, EDs should adjust their management to increase the utilization of onsite and remote PIs.

Designing in situ simulation in the emergency department: evaluating safety attitudes amongst physicians and nurses

BACKGROUND

This intervention study aimed to enhance patient safety attitudes through the design of an in situ simulation program based on a needs analysis involving thematic analysis of patient safety data and short-term ethnography. The study took place at an Emergency Department (ED) in the Central Region of Denmark. Research suggests that poor handover communication can increase the likelihood of critical incidents and adverse events in the ED. Furthermore, simulation is an effective strategy for training handover communication skills. Research is lacking, however, on how to use patient safety data and a needs analysis to the design of in situ simulation communication training.

METHODS

This is a prospective pre-post study investigating the interventional effects of in situ simulation. It used a three-pronged strategy: (1) thematic analysis of patient safety data consisting of reported critical incidents and adverse events, (2) a needs analysis based on short-term ethnography in the ED, and (3) pre-post evaluation using the validated Safety Attitudes Questionnaire (SAQ) and the Trainee Reactions Score.

RESULTS

Sixteen different healthcare teams participated composed by 9 physicians and 30 nurses. In the SAQ, participating staff scored their safety attitudes in six categories (n = 39). Two measures where significantly higher for the post-SAQ than those for the pre-SAQ: teamwork climate (p < 0.001) and safety climate (p < 0.05). The Trainee Reactions Score showed that the training was positively evaluated.

CONCLUSIONS

This study designed a feasible strategy for implementing in situ simulation based on a needs analysis of critical incidents and adverse events and short-term ethnography.

The psychological health and well-being of emergency medicine consultants in the UK

OBJECTIVE

To explore the experience of psychological distress and well-being in emergency medicine (EM) consultants.

METHODS

A qualitative, interpretative phenomenological analysis (IPA) study based on 1:1 semistructured interviews with EM consultants working full time in EDs across South West England. Eighteen EM consultants were interviewed across five EDs, the mean (SD) age of participants being 43.17 (5.8) years. The personal meanings that participants attached to their experiences were inductively analysed.

RESULTS

The analysis formed three superordinate themes: systemic pressures, physical and mental strain and managing the challenges. Pressures within the ED and healthcare system contributed to participants feeling undervalued and unsatisfied when working in an increasingly uncontrollable environment. Participants described working intensely to meet systemic demands, which inadvertently contributed to a diminishing sense of achievement and self-worth. Consultants perceived their experience of physical and emotional strain as unsustainable, as it negatively impacted; functioning at work, relationships, personal well-being and the EM profession. Participants described how sustainability as an EM consultant could be promoted by social support from consultant colleagues and the ED team, and the opportunity to develop new roles and support ED problem solving at an organisational level. These processes supported a stigma-reducing means of promoting psychological well-being.

CONCLUSIONS

EM consultants experience considerable physical and mental strain. This strain is dynamically related to consultants' experiences of diminishing self-worth and satisfaction, alongside current sociopolitical demands on EM services. Recognising the psychological experiences and needs of EM consultants and promoting a sustainable EM consultant role could benefit individual psychological well-being and the delivery of emergency care.