In this chapter I present the methods I used to collect and analyse semi-structured interviews with care home staff to inform subsequent intervention development. My specific objectives were to:
1. Explore and describe staff understanding and current practice in management of agitation and consider what knowledge, skills and support they require to manage agitated
behaviour among residents with dementia.
2. To understand what factors determine how agitation is managed in care homes and what can facilitate a shift in these factors.
I presented a poster of this work at the Alzheimer’s Association International Conference (AAIC) 2017 and a paper from this qualitative analysis has been published in BMJ Open (Rapaport et al., 2018) (see Appendix 4). I have also co-authored two papers incorporating secondary analyses of this data; one on conceptualisation of the personhood of staff, published in PLOS ONE (Kadri et al., 2018) and another on the relationship between speaking English as a foreign language and agitation in people with dementia living in care homes, published in International Journal of Geriatric Psychiatry (Cooper et al., 2017b) (see Appendix 5).
Setting, participants and procedures 4.1
Ethical approval 4.1.1
Ethical approval was given by the National Research Ethics Service (NRES) committee (London, Queen’s Square, June 2014). (See Appendix 6 for approval letter).
Recruitment and sampling 4.1.2
I recruited staff from six care homes participating in MARQUE Stream two. I purposively recruited staff from varied care home settings: residential and nursing; differing sizes;
private and charity sector; and situated in urban and rural areas.
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Research assistants with existing relationships with the care homes approached the care home managers and explained the purpose of the interviews, asking if they were happy for me to contact them to discuss this further. All of the homes we approached agreed to participate. I then contacted managers to discuss the interviews and to arrange to interview staff without impacting on care provision or staff break times. The MARQUE study budget covered replacement staff costs so that staff could participate in interviews.
After managers had agreed to participate, the researchers approached individual staff members, explaining the purpose of the study and providing information sheets (see Appendix 7 for patient information sheet). I included staff providing direct care and support to residents with dementia, including care assistants, senior carers (who had additional responsibilities), team leaders, activities coordinators, registered nursing staff and managers. I did not interview staff in solely domestic, catering or administrative roles.
I used purposive sampling to ensure I interviewed staff of either sex and differing ages, ethnicities, nationalities and different roles and experience.
Data collection 4.1.3
I interviewed staff in private rooms in the care homes, obtaining informed written consent (see Appendix 8 for informed consent form). I used my clinical skills both in setting up a comfortable and safe space for discussion and during and after the interview to maintain engagement and put participants at ease. I collected demographic information.
I conducted interviews using a semi-structured interview schedule (see Appendix 9). I developed this schedule based on the research literature, consultation with family carers of people with dementia via a focus group and expert opinion within the MARQUE team. I used open-ended questions to elicit staff perceptions of current care and I revised questions iteratively, further exploring issues raised. After completing each set of interviews (in one care home), I listened to the recordings, reflected on initial themes and revised the interview schedule to incorporate new ideas expressed by care staff, and as part of an ongoing reflective process based upon both the emerging perspectives of the participants and the interviewer (Agee, 2009). This also allowed us to check that the
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questions made sense to the participants, especially since over half did not speak English as a first language.
I ceased interviews at thematic saturation, defined as the point at which reflections on additional interviews and iterative discussions with my supervisors resulted in no further emergent themes (Guest et al., 2016). All interviews were digitally recorded and transcribed verbatim by a professional transcription company. Identifying information was removed to preserve anonymity; on completion of the analysis all recordings were deleted.
Transcripts were password protected and stored on a secure network.
Data analysis 4.2
Analytic approach 4.2.1
I have taken a thematic analytic approach based upon the work of Braun and Clarke (2006) who argue that thematic analysis represents a flexible standalone method which can be used as a tool to develop a rich and complex account of qualitative data (Braun and Clarke, 2006). Braun and Clarke highlight that although thematic analysis is not wedded to a particular epistemological position, it is important for researchers to be clear what their position is, why they have chosen a particular method and how they have undertaken the analysis. I would locate this research within a ‘contextualist’ or ‘critical realist’ position which neither denies the impact of social context upon peoples’ experiences nor overlooks their material or lived experiences (Bentall, 2009, Houston, 2001). I would see this approach as particularly fitting in care home research where the day to day experiences of staff are undeniably framed by institutional culture and social context but where the uniqueness of staff experiences in relating to people with dementia in their care can be easily overlooked (McEvoy and Richards, 2006).
I decided together with my research supervisors that this method was most appropriate to meet my research objectives. In relation to my objective to explore and describe staff understanding and management of agitation and consider what knowledge, skills and support they would need to manage agitated behaviour among residents, I have taken an inductive approach to the analytic process. This is because I am interested in the subjective
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experience of care staff and what I can learn from the data about these experiences to inform our general understanding of how agitation is managed in care homes.
In contrast, in relation to my objective to understand what factors determine how agitation is managed in care homes and what can facilitate a shift in these factors, I have taken a more deductive approach drawing upon existing theoretical understandings of what informs implementation in complex healthcare settings (French et al., 2012, Grol et al., 2007, Michie et al., 2005).
Analytic procedure 4.2.2
After listening to each interview, familiarising myself with the data and checking the transcription against the audio recording, I entered all transcribed interviews into NVivo 9 software package for qualitative data analysis. I then systematically coded the transcripts into meaningful fragments and labelled these initial codes. Each transcript was independently read and fully coded by a research assistant and we discussed and resolved any discrepancies (Barbour, 2001). I then organised the data into preliminary themes, displaying in matrices and diagrams until I had a comprehensive picture of all the phenomena in question. I discussed the coding frames within my supervisors and the research assistants involved in coding, using the constant comparison method (Glaser, 1965), identifying similarities and differences in the data in an iterative process closely grounded in the data. I sought respondent validation (Mays and Pope, 2000) on the thematic analysis by sending participants summaries of the findings, allowing them to comment on the accuracy and credibility of interpretations (see Appendix 10). In the next three chapters I will present my analysis of these interviews.
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