According to Field and Morse (1991) the main determinant when choosing the research design is the nature of the research questions to be answered. However, the final selection of the design depended on the individual beliefs and values of the researcher, their experience in doing research, the resources and time available, practicalities such as the accessibility of potential respondents and whether the research is ethically sound.
The research questions I posed for this study involved exploration of the
experiences of individuals and the support they required in their journey to become registered nurses, in other words I was interested in the real life experiences of people within a specific situational context. I concluded that a qualitative research approach should be considered.
My perspective on the social world, in other words my ontological position, is that I believe people create many and (sometimes) conflicting ‘social realities’, and that these realities may change as their constructors become more informed. This meant that in undertaking this study I wanted to explore the ‘social realities’ of the students and other individuals who played key roles in enabling a person who is dyslexic to become a registered nurse, i.e. the nursing students who were dyslexic, their lecturers, special needs support staff and clinical mentors. As a person’s viewpoint can change over time through maturity and experience, at the outset I was determined to include a longitudinal study element as part of this research strategy, to cover, in part, the three years of preparation nurses undergo to become registered practitioners.
The field of qualitative research covers a rich variety of strategies and techniques for generating data. I considered a number of ways to collect data to answer the research questions, before determining which approach to take for this study. This review is set out in the following paragraphs.
I considered doing a survey of a large number of schools of nursing (there were around 100 schools offering pre-registration nursing in the UK in 2002 when this
study commenced) using a questionnaire to ask dyslexic nursing students a range of semi-structured and open-ended questions about their experiences on the course. Parahoo (1997) identifies a number of advantages with the survey questionnaires: it is a quick and cheap way to reach a large number of
respondents spread across a wide geographical area (as compared to approaches such as face-to-face interviews and observations); and is relatively confidential and anonymous. He reports that information on “facts, attitudes, knowledge,
beliefs, opinions, perceptions, expectations, experiences and the behaviour of clients and staff’ (p249) has been collected and reported on in the nursing
literature using this method. Structured questions have an inherent degree of reliability, they allow respondents to take time to consider their responses and the anonymity might make individuals more predisposed to answer questions on sensitive or personal issues (Burton 2000).
On initial inspection this appeared to be a useful way for this study to progress, however, there were a number of disadvantages, which I felt outweighed the advantages. The most obvious disadvantage was that dyslexic individuals have difficulty with the written word and I would be selecting a method that relied on them reading and responding in a written format. Even if I was careful in
constructing the questions to reduce the requirements for large sections of free text, I was likely to get a limited response, with short and potentially superficial information. Burton (2000) rightly observes that, “there has to be a good match
between data collection methods and the abilities of respondents” (p321). If
responses were sent anonymously, there would not be any opportunity to follow up individuals unless they gave express permission to speak to me and supplied contact details. Identifying and approaching students to take part in this study had to take into account the requirements for confidentiality, especially about who knew they had a specific learning difficulty. (See page 100 for a more detailed discussion.) A one-off questionnaire would also not allow me to undertake any type of longitudinal study, to see how perceptions change over time and to track the development of coping strategies.
Wright’s (2000) study illustrates some of the disadvantages of conducting a questionnaire survey. In this study, Wright used a questionnaire, emailed to 61
schools of nursing in England, with the aim “to begin the process of discussing and
investigating the support of nursing and midwifery students with dyslexia” (p35).
He had a 46% (28) response rate from a variety of education staff working within each of the institutions and was provided with factual descriptions of the support available. The responses also included observations from respondents about issues such as the potential risk an individual who is dyslexic may pose to patients. Analysis tended to be quantitative in nature with lists of supporting processes offered to students. Wright used descriptive statistics to help
summarise the support available and he lamented the fact that institutions had provided very little information about what support there was for students in clinical practice (50% of the programme is in clinical practice). The superficiality of the information returned and with the researcher choosing not to do follow-up activities to further probe issues, such as: why institutions employed particular supporting processes, how, if at all, they supported students in clinical practice, and about the attitudes of staff to individuals who are dyslexic entering nursing, meant that there were many unanswered questions. Wright recognised the shortcomings and lists a number of questions at the end of his study that he felt needed to be investigated. Specifically Wright suggests research to consider how to support nursing and midwifery students’ accessing courses, staff attitudes to students, the assessment of risk, and how qualified staff who are dyslexic should be supported in practice.
The limitations of the questionnaire only approach are evident in this study and clearly did not allow Wright to fully address the aim of the study. The study does, however, identify the range of support currently offered to students in English universities and highlights the need for dedicated funding for additional study aids, such as computers, which at the time of the study were unavailable.
The outcome of Wright’s study suggested to me that to focus solely on one group (Wright focussed on higher education staff) might not be sufficient in dealing with this area of study, where there were many factors that come into play, e.g. staff attitudes (in school and in practice), funding issues, institution policies, student expectations and experiences.
I next considered using an interview-based strategy. Interviewing can produce a rich data set as it allows access to an individual’s attitudes and opinions (Stroh 2000). There are a number of different approaches:
• one-to-one interviews either in person or via telephone or video link; and • group interviews or focus group discussions.
While each approach varies in the conduct of the interaction, they have in common the personal, verbal expression of views by the individual, which are context free and content specific, that the interviewer can choose to pursue with the participant to increase understanding. Group interviews and focus group discussions have the added dimension of interaction between participants; ideas and insights could be sparked by another’s comments. As these are verbal exchanges it may avoid the problems encountered with written responses to a questionnaire. Questions could be rephrased if the student was unsure of what information was being sought. Interviews could be repeated so it would be possible to undertake a longitudinal study.
Interviewing either on a one-to-one or in a group basis is not without some drawbacks. Interviewing is costly in terms of time and resources, and typically generates a large volume of material that has to be managed effectively. There is also a potential problem of “interviewer bias” creeping into the interactions
(Spradley 1979). All interviewers should strive to be neutral in the way the phrase and pose questions, and avoid verbal and non-verbal communication to the respondent’s comments that might influence what they say (Polit and Hungler 1999). However, as I wished to include a longitudinal element to assess how the students progress through the programme, there would be a need for me to establish a rapport with the students. The danger here would be an over
identification with the students and a loss of perspective (Fontana and Frey 2000). Common to all data collection where individuals are invited to offer their views, there is also the possibility that the interviewees would report what they thought the interviewer wanted to hear, a phenomenon sometimes referred to as ‘social desirability’ (Parahoo 1997).
Using interviews to elicit information from the students appeared to be a suitable way to proceed, even with the potential problems highlighted in the previous paragraph, as these can be guarded against. I reflected on one of the studies I had reviewed for this study, which used a series of focus group interviews (Dale and Taylor 2001). Dale and Taylor recruited for their study, seven adult learners who were taking evening classes designed for adult dyslexic students. They held a series of three focus group discussions with the students and their two teachers with a two months gap between each event. A number of themes emerged that related to: how the individual students had been diagnosed as dyslexic; the effect this diagnosis had on them as individuals; and how their particular difficulties had coloured their previous experiences in education. What I found of equal interest were the themes related to the teachers’ model of teaching. They shared the
responsibility for teaching and opened a dialogue with the students to try to
redress the balance of power and control in the classroom. The themes to do with the teachers greatly enhanced my understanding of these students’ experience as adult dyslexic learners. My conclusion was that it was probably as important to obtain the views of the lecturers and other key individuals who support nursing students who are dyslexic as it was to acquire the views of the students
themselves. It reinforced my earlier conclusions, drawn from the review of Wright’s (2000) study, of the need to gather a range of data from a number of related
sources to achieve as full a picture as possible and be faithful to the research questions.
Having determined that individuals who supported students should be included as well as nursing students who were dyslexic, I next considered using observation as a means of data collection. Participant observation is used by a range of different social scientists and has its roots in social and cultural anthropology. Jorgensen (1989, p14) describes the ultimate aim of participant observation as “to
generate practical and theoretical truths about human life grounded in the realities of daily existence.” This method had the potential to allow me to observe the
students’ behaviour, actions and interactions with others while on placement, thus enabling me to gather data about a range of key players. Taking this approach as the principle data collection method would mean spending significant periods of time with students in clinical practice, watching their performance in carrying out
direct and indirect patient/client care and recording careful field notes and interpretations of behaviours.
Although this approach would ensure I gathered rich data about the reality of how dyslexic nurse students behave in clinical practice, I felt it raised a number of ethical issues. I agreed with Mason’s (1996) view that even overt observation carried ethical implications, specifically how a researcher built and maintained relationships in the field, the power dynamics that would operate, and the issue of informed consent. Although well reported (Jorgensen 1989; Bogdewic 1999) that as time passed in the field, observed participants accepted and accommodated the researcher, I felt that closely observing the students while they were practising would be an unacceptable intrusion and could affect their ability to learn. Having an external observer present in a clinical area was potentially disruptive to the other staff in the area and posed significant confidentiality problems in respect of the patients/clients the students were caring for. The process could also make it difficult to maintain confidentiality and privacy of the student’s diagnosis as dyslexic, which ran contra to my views that the student must be able to maintain control over who knew about their diagnosis. I therefore discounted as
unacceptable any notion of covert observation.
From an epistemological perspective, I did not feel that it was imperative to observe the students and their interactions with others in order to answer the questions. I felt that for this study I could gain greater understanding by asking key players to reflect on experiences and so explore why actions were taken, rather than just observe what actions did take place. I did identify that some carefully targeted observations could add richness to the data gathered when coupled with interviewing, provided the ethical issues identified above were managed
effectively.
I concluded, therefore, that data should be gathered from a range of sources, including: dyslexic nursing students and individuals who were involved in the selection, teaching and support of these students; and by using a range of data collection methods. I continued to feel that the inclusion of a longitudinal study following a group of dyslexic nursing students through their training would add
greater understanding of how coping strategies were developed over time. The review of the literature on dyslexia indicated that how students develop coping strategies might be (in part) dependent on the context of the environment in which they are studying. For example, as previously mentioned, Dale and Taylor’s (2001) study showed that the teachers’ model of delivery, in other words the learning context, was important for the development of study skills for adult dyslexic
learners. Therefore, the research design needed to include contextual information and the interaction between the dyslexic nursing students and their environment. These parameters suggested to me that a case study research strategy was the most appropriate way to proceed. Yin’s (1994) description of a case study as an empirical inquiry neatly summarised the research design I needed. A case study inquiry:
• “investigates a contemporary phenomenon within its real-life context;
especially when the boundaries between phenomenon and context are not clearly evident...
And
• copes with the technically distinctive situation in which there will be many more variables of interest than data points,
• relies on multiple sources of evidence, with data needing to converge in a triangulating fashion, and
• benefits from the prior development of theoretical propositions to guide data collection and analysis. ” (p13)
Yin’s position is that research questions that ask the ‘how’ or ’why’ questions are particularly well suited to case study methodology. The questions for this study revolved around ‘how’ students develop coping strategies, ‘why’ they chose
specific coping strategies in certain situations, ‘how’ external factors influenced the development of coping strategies and ‘how’ the students could be supported. Yin’s suggestion of using other theoretical propositions to guide data collection and analysis is viewed with some caution, as I did not want to dictate or narrow the field of inquiry from the outset.