Las clases medias

Drawing on Watson’s theory of transpersonal care and the wider literature reviewed in Chapter Two, a theoretical framework was developed for Stages Two and Three of the study and is diagrammed in Figure 10. The five categories from Watson (1979) and Wolf (1986) are used as independent variables, which act on perceptions of caring behaviours. Additional independent variables were used as covariates in the model: gender, age, ethnicity and profession.

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Figure 10: Independent and dependent variables acting on perceptions of caring.

Figure 10: Independent and dependent variables acting on perceptions of caring.

Independent Variables

Dependent Variables

In this diagram the right hand box lists the dependent variables which comprise caring behaviours as perceived by health care professionals and patients. Those perceptions have been sourced by observing caring interactions between the two groups and then analysing the observed data by means of follow-up interviews. In the left hand box the independent variables are listed these include Watson’s caring caratives which are used to define and group caring behaviours.

5 Carative Categories (Watson, 1979; Wolf, 1986) 1. Respectful Deference

Two carative interventions, (1) developing a helping- trusting relationship and (2) encouraging and accepting expressions of positive and negative feelings. Encompasses honesty, showing respect and provision of information.

Assurance of human presence

Three carative interventions, (1) formation of a humanistic-altruistic system of values, (2) instillation of faith-hope, and (3) cultivation of sensitivity to one’s self and to others. Encompasses talking with the patient, helping the patient, appreciating the patient as a human being and responding promptly to the patient’s call for assistance.

Positive connectedness

One carative intervention, (1) provision for a supportive, protective, and/or corrective mental, physical,

sociocultural, and spiritual environment.

Encompasses behaviours such as allowing the patient to express feelings, trusting the patient and being hopeful for the patient

Professional knowledge and skill

Two carative interventions, (1) scientific problem-solving approach for decision making and (2) promoting interpersonal education and learning. Encompasses watching over the patient, paying special attention to the patient on the first visit and being confident with the patient.

Attentiveness to the other’s experience Two carative interventions, (1) assistance with gratification of human needs and (2) allowance for existential-phenomenological forces. Here caring behaviours such as putting the patient first, relieving the patient’s symptoms and giving good physical care are included (Brunton & Beaman, 2000).

Covariates  Gender  Age  Ethnicity  Profession  Education PERCEPTION OF CARING BEHAVIOURS Health care professionals Patient Source -Observation and interview

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Finally age, gender, ethnicity, profession and level of education are variables used to determine if these influence perception of caring behaviours between the two groups. 6.3. Development of the observation tool

A preparatory visit was made by the researcher to both wards so that initial activity could be ascertained. Difficulty was encountered due to the rapid and large amount of information observed at any one time. This difficultly in information gathering in observational study has been acknowledged by previous researchers in the field (Bowman, 1995; Johnson, 1995; Martin & Bateson, 2007). The need to watch and listen continuously was imperative (Hammersley & Atkinson, 2007; Schatzman & Strauss, 1973). It was decided to develop the observational tool so that the caratives of Watson’s (1986) caring theory could be captured in a semi-structured way which liberated the researcher from the assumed and accepted; thereby revealing a richer field for observation. Field notes were made following every observation; this was done in a quite office away from the ward. No notes were taken whilst observing or assisting with caring interactions. Each observation was numbered and notes written were anonymised so that no participants would be identified. To illustrate this, patient participants were referred to in the field notes as P1 for patient one and so on.

6.3.1. Modifying the observation tool

During the preparatory stage of observation of the two wards involved in the study, the researcher experienced difficulty recording all the information observed at the one time without losing track of unfolding events. This has been documented in the literature and acknowledged as an on-going problem in observational studies (Bowman, 1995; Johnson, 1995; Martin & Bateson, 2007).

On completion of the preliminary ward observations, the observation tool was modified to allow for easier data recording. The revised tool was:

 Semi-structured

 Comprised of sections for date, time, ward, personnel involved, activity/interaction, verbal behaviour, physical behaviour and gestures.

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 Documented patient condition or traumatic injuries.  A free text section for notes and comments.

 A box for recording a unique code for each participant (Appendix 13).

Reflective comments following each observation period were made which allowed for the recording of any thoughts or feelings. These could be explored soon after the event and any concerns clarified by the staff involved. For example, on one occasion on the trauma orthopaedic ward a physiotherapist was heard to refer to a particular piece of equipment she was giving to a patient as an abbreviation, this was discussed with the member of staff and the data recorded clarified.

6.3.2. Capturing the data

Attempting to capture the caring interaction in the fullest sense can be a monumental undertaking, it was decided by the researcher to look at ways in which data collection could be enhanced. The use of tape recorders in participant observation has been documented and can help provide far more detail than notes.

The use of audio and video recordings in the collection and analysis of data was first used in the 1940s and 1950s by several social scientists (Bateson and Mead, 1942; Bateson, 1956; Birdwhistell, 1952). In recent years the importance of data recording has been acknowledged by ethnographers (Hammersley and Atkinson, 2007), social psychologists (Potter and Wetherall, 1987) and in researcher methods using focus groups (Barbour and Kitzinger, 1999). One of the fundamental benefits of using recording equipment is that it is less prone to the interpretive filtering effect which occurs when the researcher is writing down their version of the observed events. The account of the observation is therefore likely to be more accurate and detailed (Hammersley and Atkinson, 2004). There are those who emphasize what they perceive as distinct disadvantages to tape- recording interactions. Some researchers worry about the effects and influence such equipment can have on study participants, such as researcher effects (Bryman, 2004; Hammersley, 1991), context effects (Foddy, 1993) and observer effects (Robson, 2011).

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Sacks (1984) describes the positive use of tape-recorded conversations in observation, concluding that, ‘The tape-recorded materials constituted a good enough record of what had happened. Other things, to be sure, happened, but at least what was on the tape had happened (P.26). The researcher decided that recording the exact conversation during the caring interaction was important in helping to capture the integrity of the social processes under observation. Employing the use of a digital recorded allowed for a reduction in background noise from other conversations and activity in the observation area. The recorder was discreetly placed in the researcher’s uniform top pocket.

6.3.3. Respecting privacy and dignity

All patients were informed of their right to decline observation during intimate personal care, at such times the researcher would either leave the area completely or stand outside the bed screens until the procedure had finished. Patient privacy and dignity were protected at all times.

6.3.4. Sample demographics

The stratified random sample participants were drawn from one orthopaedic trauma ward and one elective orthopaedic ward. A total of 16 health care professionals and 8 patients agreed to take part in this stage of the research. See Chapter 4 tables 4.10 and 4.11. 6.3.5. Inclusion Criteria

Each participant was assigned a number for the study in order to protect their identity and to ensure confidentiality. The inclusion criteria for selection of patients for observation and follow-up interview were as follows:

 In-patient on either the elective orthopaedic or orthopaedic trauma ward during the observation session.

 Alert and orientated to give informed consent and willing to participate in a post- discharge interview.

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 Can speak English.

 Well enough to participate Inclusion criteria for staff participants:

 Participation consent obtained

 On duty during the observation period.

Staff and patients interested in the study were given an information sheet (Appendix 6 and 7), any questions were fully answered and written consent was obtained (Appendix 8 and 9).

6.3.6. Gaining access to potential participants

The specialty matron and ward managers for each ward were approached by the researcher for permission to (a) conduct the observations on the given wards and (b) access potential participants.

In order to increase the number of potential study participants, each ward was visited at times indicated by each ward manager when staffing levels were at their maximum. Between 09.00 - 12.30hrs for morning shifts, 14.00 – 19.00hrs for afternoon shifts and 20.00 – 24.00hrs for night shifts.